GENERAL MEDICINE

GM- CASE 3

Tuesday, 7 March 2023

7 March 2023
CASE scenario....

Hi, I am k.saimadhuri 3rd year bds 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 HISTORY : A 60 year old known case of abdominal pain 
CHIEF COMPLAINTS : abdominal pain since 5 days,dry cough since 5 days fever and breathlessness since 3 day 

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic  2 years ago,then abdominal pain started ,it is at left hypochondrium, it is non radiating ,it is sudden in onset ,it is burning type pain in abdomin. Fever since 3 days ,it is intermittent with chills ,no aggregating and relieving factors. Cough is dry it is incidious in onset, gradually progressive in nature ,it is associated with chest pain. Breathlessness since 3 days on coughing and progressive from grade 2 to grade 3 . Decreased urine out put .

PAST ILLNESS :
Not a know case of diabetes, hypertension 
Known case of renal failure 

PERSONAL HISTORY : 
Mixed diet, apatite is normal, have proper sleep, regular bowel, no habits.

FAMILY HISTORY : 
Not significant 
GENERAL EXAMNLINATION : 
Built : moderately built
Nourishment : moderately nourished
Consciousness: in Conscious
Pallor : no 
Icterus : no 
Cyanosis : no cyanosis 
Clubbing : no clubbing 
Lymphadinopathy : no lymphadenopathy 
Edema :pitting type of pedal edema till knee since 3 days
 Diagnosis: Acute kidney infection 
     
Q/A

1.  Is this curable or it needs any surgery 

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