GENERAL MEDICINE

General Medicine

21st 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 55yr old male resident of munagoodu, occupation by lorry driver, chief complaint: 

      Puffiness of face since 1 month

      Pedal edema since 1 month. 

     Decreased urine output since a week

History of present illness

Patient was asymptomatic apparently before a month ago, then developed puffiness on face , pedal edema which is started initially in lower limb gradually progressed towards knees. 

 And decreased urine output since a week.

 

History of past illness: 

   Known history of diabetes and hypertension since 15 yrs

 No history of seizures 

  No history of asthma

 No history of tuberculosis

 No history of CVA

 No history thyroid disorders

Personal details: 

  Occupation: lorry driver

  Appetite: normal

  Diet: mixed 

  Bowel: regular

 Micturition: normal

 No known allergies

 

Habits : alcohol consumption.

Family history: not significant.

General examination: 

Built : normal

Consious, coherent and co operative.

Pallor: no

Cyanosis: no

Lymphadenopathy: no

Icterus: no

Clubbing: no

Edema : present

Malnutrition: no

Dehydration: no

Vitals: 

Temperature: 98F

Pulse rate: 88/min

Respiratory rate: 22/min

Bp: 120/80 mmHg

Systemic examination:

  CVS: no cardiac murmurs

  Respiratory: no dyspnea

                        No wheeze

               Position of trachea - central

                

Abdomen : shape - scaphoid

                     No tenderness

No organomegaly

CNS : consious and alert

Provisional diagnosis: 

             Diabetic nephropathy associated with hypertension and end stage renal disease.