General Medicine Case Discussion
August 17,2022
usg abdomen
culture
Case scenario.......
Hi, I am M.Yamini , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
52 year old female occupation,house wife came from suryapet to general medicine department
Chief complaints:
Anuria since 1 week
HISTORY OF PRESENT ILLNESS:
Patient Was apparently Asymptomatic but develops bilateral pedal edema since 3 months ,Shortness of breath developed 1 month back,Anuria since 1 week .
No c/o chest pain,sob
PAST HISTORY:
She is known case of DM& hypertension since 10 years
PERSONAL HISTORY:
Appetite: Normal
Diet: mixed
Bowel movement present
Sleep:adequate
No addiction s
FAMILY HISTORY: insignificant
Drug history:No
GENERAL EXAMINATION:
Patient is conscious, coherent,cooperative,i and moderately built & moderately nourished
Icterus: absent
Pallor: absent
Clubbing: abesnt
Edema: present
No generalized lymphadenopathy
Jvp Normal
SYSTEMIC EXAMINATION:
Cardiovascular system:
Cardiac sounds: S1, S2 heared
Respiratory system:
dyspnea present
NO wheezing
Breath sounds heard: vesicular Normal
Abdomen:
Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
USG abdomen
PROVISIONAL DIAGNOSIS:
Chronic kidney disease.