THIS IS AN ONLINE UG CASE LOG WHICH IS A RECORD BOOK /E-PORTFOLIO WHERE MBBS/NURSING/ALLIED HEALTH UNDERGRADUATE STUDENTS DOCUMENT ALL THE CLINICAL CASES THEY SEE, ASSIST, OR PERFORM DURING THEIR POSTINGS.
[6.03 pm, 30/10/2026] hu2: Here are your 2 cases made into proper, de-identified record format. No name / address / hospital number.
*CASE RECORD - 1*
*DEPARTMENT OF GENERAL MEDICINE*
*Demography:* 49 years / Female
*Date of Admission:* 14th October 2026
*Informant:* Patient herself
*CHIEF COMPLAINTS:*
1. Swelling of both feet - 7 days, aggravated
2. Breathlessness - 3 days
3. Decreased urine output - 2 years
*HISTORY OF PRESENT ILLNESS:*
Patient was apparently asymptomatic 5 years ago. She was then diagnosed to have Type 2 Diabetes Mellitus and Systemic Hypertension on routine evaluation.
5 years ago, she developed swelling of both feet. Initially over ankles, insidious in onset, gradually progressive to involve entire leg up to thighs. Bilateral, pitting in nature, more in evening, relieved on lying down with legs elevated. Associated with facial puffiness in morning.
4 years ago, she noticed decreased urine output, progressive in nature, now ∼200 ml/day. No history of dysuria, hematuria, burning micturition, increased frequency, passage of gravels.
3 years ago, evaluated with blood tests and diagnosed as Chronic Kidney Disease. No history of NSAID abuse.
Since 18 months, patient is on Maintenance Hemodialysis - 3 times per week, 4 hours per session, via left radiocephalic arteriovenous fistula. History of orthopnea present. No PND.
No history of fever, productive cough, chest pain, wheezing, palpitation, syncope.
*PAST HISTORY:*
K/C/O Type 2 DM - 8 years - on Metformin 500mg + Insulin
K/C/O HTN - 8 years - on Telmisartan
K/C/O CKD - 3 years, on Hemodialysis - 18 months
No H/O TB, bronchial asthma, COPD, major surgery, blood transfusion
*PERSONAL HISTORY:*
Appetite - decreased, Diet - mixed, Sleep - disturbed, Bowel - regular, Bladder - oliguric, No addictions, No smoking / alcohol
*FAMILY HISTORY:*
Father - Type 2 DM, HTN
No family history of kidney disease
*GENERAL PHYSICAL EXAMINATION:*
Conscious, cooperative, well oriented to time, place, person
Built - average, Nutrition - average
Pallor - present, Edema - present - B/L pitting pedal edema + facial puffiness
Icterus, Cyanosis, Clubbing, Lymphadenopathy - absent
Vitals: BP - 160/90 mmHg, Pulse - 88/min, RR - 24/min, Temp - 97 F, SpO2 - 94% on RA
*SYSTEMIC EXAMINATION:*
CVS: S1 S2 heard, no murmur
CNS: NFND, no focal deficit
RS: NVBS, bilateral air entry present
P/A: Soft, non-tender, no organomegaly
*Local Examination:* Left forearm AV fistula - scar present, thrill palpable
*PROVISIONAL DIAGNOSIS:*
Chronic Kidney Disease Stage 5D on Maintenance Hemodialysis, likely Diabetic Nephropathy with Hypertensive Nephropathy, with fluid overload state.
*CASE RECORD - 2*
*Demography:* 49 years / Male, Worker
*C/O:* Decreased urine output - 2 years, SOB on exertion - 2 years, B/L pedal edema - 2 years, associated with pain on walking
*HOPI:* Apparently asymptomatic 2 years ago, then diagnosed as CKD on blood test. Swelling started at ankles, progressed to entire leg, pitting type, no itching. Breathlessness gradually progressive. No dysuria. On hemodialysis since diagnosis.
*Past / Personal:* Similar, no addictions noted
*On Exam:* B/L pitting pedal edema
*Provisional:* CKD Stage 5D on MHD.
---
*Investigations to attach:*
CBC, RFT with eGFR, S. Electrolytes, S. Calcium, Phosphate, iPTH, ABG, Urine Routine, HbA1c, ECG, CXR, USG KUB.
*Charts to maintain:*
Input-Output, Daily Weight, Blood Pressure chart, Dialysis chart.
CASE SUMMARY
Age/Sex: 36-year-old female
Address: muthangi, Hyderabad
Chief Complaints:
1. Bilateral lower-limb swelling for 4 years.
2. Abdominal pain for 4 years.
History of Present Illness:
A 36-year-old female, a known case of chronic kidney disease (CKD) on maintenance hemodialysis two times per week (as reported), presented with bilateral lower-limb swelling and abdominal pain for 4 years.
Past History: Known case of CKD on maintenance hemodialysis.
General Examination: Bilateral pedal edema present. Other findings and vital signs examined and documented.
Systemic Examination:
* CVS: S1 and S2 heard; murmurs assessed.
* RS: Bilateral air entry assessed; added sounds assessed.
* Per Abdomen: Abdomen distended; tenderness, organomegaly, and shifting dullness assessed.
* CNS: Consciousness, orientation, and neurological status assessed.
Provisional Diagnosis: Chronic kidney disease on maintenance hemodialysis with bilateral pedal edema and abdominal distension, with abdominal pain.
27/10/2026
28/10/2026
29/10/2026
30/10/2026
CASE SUMMARY
Age/Sex: 36-year-old female
Chief Complaints:
1. Bilateral lower-limb swelling for 4 years.
2. Abdominal pain for 4 years.
History of Present Illness:
A 36-year-old female, a known case of chronic kidney disease (CKD) on maintenance hemodialysis two times per week (as reported), presented with bilateral lower-limb swelling and abdominal pain for 4 years.
Past History: Known case of CKD on maintenance hemodialysis.
General Examination: Bilateral pedal edema present. Other findings and vital signs examined and documented.
Systemic Examination:
* CVS: S1 and S2 heard; murmurs assessed.
* RS: Bilateral air entry assessed; added sounds assessed.
* Per Abdomen: Abdomen distended; tenderness, organomegaly, and shifting dullness assessed.
* CNS: Consciousness, orientation, and neurological status assessed.
Provisional Diagnosis: Chronic kidney disease on maintenance hemodialysis with bilateral pedal edema and abdominal distension, with abdominal pain.
[6:29 pm, 31/10/2026] hu2: How many patients over how many days?
Please ask everyone else to also mention that along with the dates these were taken
[6:31 pm, 31/10/2026]hu3: 4 patients sir
2 CKD cases and 2 medicine ward cases
Then 2 follow ups
From 20th october to 29th october
Before 20th you had demonstrated examination on around 3-4 patients sir
[6:31 pm, 31/10/2026] hu2: Share all four with their follow ups
[6.33 pm, 31/10/2026] hu2: 23 October 2026. Dengue case
[6.33 pm, 31/10/2026] hu3: 26 October 2026 CKD case
27 October 2026 Hypertension case
28 October 2026 Appendicitis case
29 October 2026
30 October 2026 Pain in the knee
27th October Arthralgia case
28th October Appendicitis case
30th October
26th October CKD patient
23rd October CKD patient
26/10/2026
27/10/2026 28/10/2026
6.43 pm, 31/10/2026] hu3: Good morning sir!
Our posting commenced on 19th October. However, as per your instructions, we were asked to start taking cases from 26th October. Accordingly, a total of 5 cases have been handled so far.
[6.48 pm, 31/10/2026] hu3: Good morning Sir this is the case of CKD stage 5
27/10/26
[6.48 pm, 31/10/2026] hu3: Sir this is the case I have taken tdy 30/10/26
Dengue along with typhoid
[6.48 pm, 31/10/2026] hu3: Sir this is case of swelling over neck along with seizures
[6:48 pm, 31/10/2026]hu3: These are all reports sir
[6.48 pm, 31/10/2026] hu3: Sir this is case of intratrochanteric fracture 26/10/26
[6:48 pm, 31/10/2026] hu2: Thanks for sharing.
Make it a point to always removing identifiers from any documents that you share online and also taking patient consent from here: https://pajrhealth.com/join/details/
No comments:
Post a Comment