GENERAL MEDICINE

General medicine

19th August, 2023

Case scenario,

      Hi I'm Aishwarya 3rd bds student. This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio. 

Case history:

  Patient details:

        A 57 year old male occupation by farmer, presented with the cheif complaints of pedal edema since 10 days and shortness of breath since 5 days.

History of present illness:

      Patient was apparently asymptomatic 1 month ago, then felt weakness and after regular checkup he was diagnosed with deranged renal parameter. since 10 days he had pedal edema which is pitting type upto knee.   Also complains of shortness of breath since 5 days [grade 2 gradually progressive]. Decreased urine output since 5 days. 

History of past illness:

    Known complaint of hypertension since 2 months.

Diabetes: no

CVA: no

Epilepsy: no

Asthma : no

Tuberculosis: no

Thyroid disorders: no

Personal history: 

   Occupation: farmer

   Appetite: normal

   Diet : mixed 

   Bowels : regular

    Micturition: decreased since 5 days

   No allergy towards any drugs.

Habits: alcohol regularly since 30yrs

              Cigarette pack per day since 40yrs

Family history: not significant

General examination: 

  Pallor : present

  Cyanosis: no

  Lymphadenopathy: no

  Malnutrition: no

  Dehydration: no

  Icterus: no

  Clubbing: no

  Edema : present pitting type

Vitals: 

Temperature: 98F

Pulse rate: 100/min

Respiratory rate: 25

Bp: 140/80

Systemic examination: 

 CVS: normal , s1 s2 +ve.

           No cardiac murmurs.

Respiratory: shortness of breath since 5 days.

Abdomen: scaphoid , no tenderness

                    Liver and spleen are not             palpable 

CNS: consious and alert

           Normal speech.

Provisional diagnosis: 

     Chronic renal failure with anemia.

Investigations: 

     Complete blood picture: done

      USG of abdomen : done