GENERAL MEDICINE

General Medicine

26th 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 65yr old male occupation by weaver, resident of chittyal presented with the chief complaint of :

     Swelling in the lower right limbs since 4 days

History of present illness: 

  Patient was apparently asymptomatic 15 days ago, them developed swelling in the right lower limb which is insidious onset them gradually progressed.

There is local rise in temperature.

Redness present

Discoloration of skin.

Blebs are present.

History of past illness: 

Known complaint of filariasis since 15 yrs.

Diabetes: no

Hypertension: no

Asthma: no

CVA: no

Thyroid diseases: no

Edema: present 

Tuberculosis: no

Epilepsy: no

Personal history: 

Occupation: weaver

Appetite: Normal

Diet : mixed

Bowels : normal

Micturition: normal

No known allergies.

Habits: 

       Occasionally alcohol consumption.

Family history: 

      Not significant.

General examination: 

 Built : normal

Patient was conscious, coherent and co operative.

No pallor

No icterus

No cyanosis

Pitting edema of feet present 

No clubbing

No lymphadenopathy

Vitals: 

Temperature: afebrile

Pulse rate: 100 / min

Respiratory rate: 20/ min

Bp: 130/80 mmHg 

Systemic examination: 

CVS: s1 s2 +ve

          No cardiac murmurs

 

Respiratory: no wheeze

                      No dyspnea

                 Position of trachea is central

Abdomen: 

 Shape: scaphoid

 No tenderness

 Liver and spleen are not palpable

 

CNS : consious

            Speech is normal

Provisional diagnosis: 

           Cellulitis of right lower limb.