GENERAL MEDICINE E-LOG AUG-07/08/2021

 04 KAVYA SREE(OLD BATCH)

45 YEARS MALE....

AUG 07-08-2021

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

CASE :

A 45 yr old male , came to the opd with chief complaints of 

Pedal edema since 2 month  and

Shortness of breath since 2 month 

HISTORY OF PRESENT ILLNESS : 

Pt was apparently asymptomatic 2 months back later he developed with facial puffiness, shortness of breath and pedal edema since 2 month.

Pedal edema which is gradual in onset,progressive in nature ,pitting type upto knee .

SOB since 1 month -  grade 2 dyspnea.

PAST HISTORY : 

No history of similar complaints in the past 

Not a k/c/o of diabetes ,tb, epilepsy, asthma

k/c/o HTN-1 year.

PERSONAL HISTORY :

Married 

Sleep : adequate 

Appetite : Decreased, stopped taking non veg food. 

Bowel and bladder movements : regular

Alcohol and tobacco consumption: 

History of alcoholic consumption: occasional 

No history of tobacco consumption

FAMILY HISTORY :

No significant family history 

CONSENT OBTAINED 

General physical examination:

The patient is conscious, coherent and cooperative, sitting comfortably on the bed.

- He is well oriented to time, place and person.

- He is moderately built and moderately nourished.

Pedal edema is noticed which is of pitting type progressive in nature,extending up to the knees 

Pallor present 

No signs of icterus ,cyanosis , lymphadenopathy, malnutrition, dehydration 

Pulse = 82 beats per minute, regular.

- Blood pressure = 140/90 mm of Hg 

- Respiratory rate = 18 cycles per minute 

-SPO2=98%

-GRBS=109mg%

Systemic Examination:-

Cvs: 

S1,S2 heard

No Thirlls and murmurs. 

Respiratory: position of trachea-Central.

Breath sounds- vesicular

ABDOMEN:

Shape: Scaphoid.

            no tender and palpable mass.

CNS: Normal.

Provisonal diagnosis :Chronic renal failure.

                               

INVESTIGATION:

                                                 DOPPLER 2D ECHO

                             

                                                              

ECG:

   

REPORT:

EXAMINATION:

PALLOR:-

PITTING EDEMA:-

TREATMENT:

One session of hemodialysis done on 06/08/2021.