GENERAL MEDICINE

 GENERAL MEDICINE 

February 21st,2023

GM-CASE 2

Tuesday,21st February 2023

21st February 2023

Case scenario....

Hi I am G sukanya, 3rd bds student. This is an online elog book to discuss our patient health data after taking her consent. This reflects my patient centered online learning portfolio. 

Case history: 

A 65 years old female Resident of Nirmal presented with the

Chief Complaint of

Shortness of breathe and patient is having edema of feet since 1 week .

Present illness

Patient was apparently normal 1 week back and then had Shortness of breathe and pedal edema and brought to the hospital and diagnosed as chronic kidney failure. And only two episodes of dialysis is completed. 

Past illness 

hypokalemia is present and she is using medicine to increase the level of potassium.

Personal  history 

1)Diet:mixed diet 

2)apetite:loss of apetite 

3)sleep:inconvenience in sleeping 

4)Bowel:regular bowel

5)Micturition:Regular micturition 

Family  history 

Diabetes:No

Hypertension:No

General examination 

Built:thin

Nourishment:poor

Consciousness:present 

Pallor:pale pink

Icterus:not present 

Cyanosis:No

Clubbing:No

Lymphadenopathy:No

Edema:pitting edema extended upto knees from feet without any pain.

Vitals 

Pulse rate:86bpm

Blood pressure:140/80mmHg

Drug history 

          

             PROVISIONAL DIAGNOSIS 

      

              ----RENAL FAILURE-------

Q/A

1) Is dialysis is only the way to get rid of Renal failure?

2)How many episodes of dialysis should I have to take ?

3) Can we proceed to kidney transplantation instead of dialysis?

4) Is there any other consequences of chronic kidney disease?