GENERAL MEDICINE E-LOG

-

32 CH SRILEKHA

Hello everybody, This is ch srilekha , a third semester medical student .

This elog depicts the patient- centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients  de-identified health data shared , after taking his/her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

Under the guidance of Dr. Bhavya sree mam Intern

A 44 year old male patient , farmer by occupation  came to OPD with chief complaints of 

Pedal edema since 3 months 

Shortness of breath while walking 

HISTORY OF PRESENT ILLNESS

The patient was apparently  asymptomatic 1 and half year ago , then developed pitting type of pedal edema below the knee  , which was gradual onset and progressive then developed SOB  [grade III -IV]. 

He has decreased urine output

He has tested positive for covid-19 before 3 months.

He consumes alcohol [90 ml] and stopped taking since last  3 months.

HISTORY OF PAST ILLNESS

known case of  Chronic Kidney Disease since 1 1/2 year 

known case of Hypertension since 1 year [on tab CILACAR 10mg - morning, 20mg - night].

 Not known case of DM ,Asthma, TB,Epilepsy .

PERSONAL HISTORY

He is married

Occupation - farmer 

Diet - Mixed

Appetite - Normal

Bowels - Regular

Micturition - decreased urine output

He has no known allergies

Alcoholic since 20 years and stopped 3 months back

No smoking 

TREATMENT  HISTORY

No specific treatment history

FAMILY HISTORY

No significant family history

DRUG HISTORY

He has been using Tab. CILACAR 10mg - morning, 20mg -night for Hypertension since 1 year.

GENERAL EXAMINATION

    Patient is conscious,coherent, cooperative and examined in well lit room.

VITALS

Pulse rate -94bpm

Respiratory rate - 18/min

BP - 140/90mmHg

 Temperature - Afebrile

SpO2 - 98% at room air

GRBS - 141mg%


PHYSICAL EXAMINATION

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing of fingers/toes - absent

Lymphadenopathy - absent

Edema of feet- present,pitting type 




Malnutrition - absent

Dehydration - absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

  • S1 and S2 heard
  • No thrills
  • No cardiac murmurs
RESPIRATORY SYSTEM 

  • Vesicular breath sounds heard
  • Trachea is shifted to left
  • No wheezing
  • Dyspnea present
  • Orthopnea present
  • No adventitious sounds heard
ABDOMEN

  • Obese shaped abdomen
  • No tenderness
  • No palpable mass
  • Hernial orifices - normal
  • No free fluid
  • No bruits
  • Liver and spleen are not palpable
  • Bowels sounds are heard


CNS

  • Conscious,normal speech
  • No signs of meningeal irritation
  • Normal gait
  • Cranial nerves are intact 
  • Motor system normal
  • Sensory system normal
  • Reflexes normal

INVESTIGATIONS

29/7/2021

ULTRASOUND



ECG



HEMOGRAM


COMPLETE URINE EXAMINATION


BLOOD UREA


SERUM ALBUMIN


TOTAL SERUM PROTEINS(A/G RATIO)



SERUM CREATININE



4/8/2021

SERUM ELECTROLYTES

SERUM IRON


PROVISIONAL DIAGNOSIS

Chronic Renal Failure

TREATMENT

T.Lasix 40 mg PO/BD

T.Cilacar 10 mg PO/OD

T.Nodosis 500mg PO/OD

T.orofer XT PO/BD

T.Cilacar 20 mg PO/OD

Inj.Erythropoietin 4000IU (weekly twice)

Fluid Restriction <1.5L/day

Salt restriction <4gms /day


 

 


Comments

Post a Comment

Popular posts from this blog

General medicine E-log

-
Image
32 CH SRILEKHA, 8th sem This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio. 58 yr old with stroke November 28, 2023 58 year old male construction worker by occupational came with chief complaints of Burning sensation at right upper half of the body since 2years History of present illness Patient was apparently asymptomatic 2years than one night he suddenly  complained  of loss of vision in both eyes and he developed weakness of right upper limb and lower limb and deviation of mouth to left side which is sudden in onset preceeded by 30-40 episodes of vomiting non-bilious , non-blood tinged, projectile which was associated with involuntary movements of both upper limbs and lower limbs , associated with frothing , tongue bite , outward fixation of l
Read more

General medicine E-log

-
Image
32 CH SRILEKHA, 8th sem This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio. 55 year old male came to opd with chief complaints of fever and yellowish discoloration of eyes and tongue( jaundice) since 15days HISTORY OF PRESENTING ILLNESS  Patient was apparently asymptomatic 15 days ago when he developed fever which was insidious in onset, low grade, gradually progressive in nature, associated with chills and rigors. No hlo loose stools, vomitings Pedal edema was noted by patient 2 days ago, pitting type No h/o decreased urine output or burning micturation. H/o cough since 1 day, non productive, dry cough. No hlo chest pain, palpitations and sob H/o yellowish discoloration of eyes and tongue since 15 days No h/o bleeding per rectum, haematuria . PA
Read more

General medicine E-log

-
Image
32 CH SRILEKHA, 8th sem This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio. CHEIF COMPLAINTS:  28 years male autodriver by occupation admitted in hospital with c/o fever since 5 days HOPI: patient was apparently asymptomatic 5 days back then he developed intermittent low grade fever a/w generalised body pains, headache, and giddiness. Lots of appetite, not a/w chills and rigor no diurnal variation  No history of malena, hematuria No complaints of chest, pain, cough, cold No complaints of burning micturition No complaints of loose stools, nausea, vomiting PAST HISTORY : Not a known case of hypertension, diabetes, thyroid, CAD CVA TB PERSONAL HISTORY: Appetite: normal Diet: mixed Addictions: no Sleep: adequate bowel regular  General examination: Pt
Read more