GENERAL MEDICINE E-LOG

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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


 

 


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