general medicine blog4

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : Maheshwari gulla
Roll no : 44

2020 Batch

I''ve been given this case to solve in an attempt to understand the topic of "PATIENT CLINICAL DATA ANALYSIS" to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and comeup with Diagnosis and Treatment plan.

A 65 years old male came to OPD with
Chief complaints of: swelling in abdomen and cough since 10 days

History of present illness: patient was asymptomatic 10 days ago later he developed swelling in abdomen and break in urinary stream and he also had cough since 10 days and he has swelling in the region of neck since 10 years  with this symptoms he visited nalgonda govt hospital he adviced to visit Kim's for dialysis  

Past history
No diabetes mellitus
No hypertension
No asthma
No TB
No known allergies
 
Family history 
No family history'

PERSONAL HISTORY:
Marital status: married 
Occupation: farmer
Appetite: normal
Diet: mixed
Bowel : regular 
Micturation: abnormal 
Addictions: alcoholic and smoker 20 years back

GENERAL EXAMINATION:
Conscious,  coherent, co-operative Moderately built, nourished. 
PALLOR: ABSENT 
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
 EDEMA Of FOOT : PRESENT 

 VITALS 
TEMPERATURE: 98.7  F
PULSE RATE:840beats /min
RESPIRATORY RATE: 28 Cycles/min
BP:180/100mm of hg 
SPO2:98% at room air

SYSTEMATIC EXAMINATION 
CVS:
S1,S2 Sounds heard

RESPIRATORY SYSTEM:
Dyspnea is absent 
Wheeze is absent
Position of trachea:central
Adventitious sounds : crepts present

ABDOMINAL EXAMINATION :
INSPECTION:
abdomen : obese
Palpation
No local rise of temperature
Tenderness present
No Palable mass 
Liver and spleen not palpable
Percussion
Free fluid present
Ascultation
Bowel sound are heard

INVESTIGATION
DIAGNOSIS: bilateral pleural effusion
Grade2 rapid pelvis dilation in bilateral kidneys with bilateral cortical cyst

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