General medicine e log 2

 Hi,I am Tharun 3rd sem medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio 

A 45 years old male came with SOB, B/L pedal edema 

CHEIF COMPLAINT:c/o SOB, B/L pedal edema since one month 

HOPI: patient was apparently asymptotic 1 month back then he developed SOB and pedal edema 

HISTORY OF PAST ILLNESS: 

K/c/o Hypertension (3 years)

TREATMENT HISTORY :

No diabetes , CAD, asthama, TB 

PERSONAL HISTORY :

Apetite normal 

Micturation normal 

Bowels - regular 

FAMILY HISTORY : 

Diabetics - NO 

Hypertension - NO 

Heart disease - NO 

Stroke - NO 

PHYSICAL EXAMINATION 

GENERAL : 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers 

No lymphadenopathy 

No Oedema of feet 

No malnutrition 

No dehydration 

Pulse rate : 86/min 

Respiration rate : 16/min 

BP : 140/80 mm/hg 

SPO2 at room air 98% 

SYSTEMIC EXAMINATION 

CARDIO VASCULAR SYSTEM 

No thrills 

S1 S2 cardiac sounds 

Cardiac murmurs - NO 

RESPIRATORY SYSTEM 

Position of trachea - central 

Breath sounds - vesicular 

ABDOMEN 

Tenderness - not 

Palpable mass - no 

CENTRAL NERVOUS SYSTEM 

Conscious 

Speech - normal 

Reflexes are present 

PROVISIONAL DIAGNOSIS 

CKD on MHD 

PLAN OF CARE : dialysis 

INVESTIGATIONS 
























ECG 


MEDICATIONS 






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