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 






Comments

Post a Comment

Popular posts from this blog

78 year old male came to OPD with chief complaints of bilateral pedal edema since 2 months

 A 78 year old male came to OPD with chief complaints of bilateral pedal edema since 2 months HOPI Patient was apparently asymptomatic 2 months back then he developed bilateral pedal edema (pitting type) which was sudden in onset and gradually progression. PAST HISTORY - Known case of hypertension since 1 year and using medication for it (clindipine) - Similar complaint of pedal edema an year ago and it was relieved by medication  No DM No TB No Syphilis No CVA No CAD - H/O surgery for renal calculi 5 years back  Family history. No significant family history Drug history Patient is on clindipine since 1 year Personal history Diet - Mixed Appetite - abnormal Bowel movements - irregular Bladder movement - regular Sleep - adequate No allergic history Addictions Consumes alcohol and tambaku PHYSICAL EXAMINATION A. General Examination Conscious  coherent and cooperative Moderately built No pallor No icterus No cyanosis No clubbing of fingers No lymphadenopathy Pedal edema VITALS. Temperatur
Read more

A 30 yr old female patient came to opd with chief complaints chest pain and pain at back of chest

 A 30 yr old female patient came to opd with chief complaints chest pain and pain at back of chest  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 6 months back,then she developed chest pain which was episodic for every 15 days,pain was aggregating while breathing and doing work,and reliving during medication, pain was radiating towards the back of chest  PAST HISTORY: She had undergone with hysterectomy 6 years back  N|K|C|O  Hypertension, Diabetes, epilepsy, asthma, TB FAMILY HISTORY: Not relevant Drug history: Nil PERSONAL HISTORY: Diet : Mixed Appetite : normal Sleep: inadequate due to chest pain Addictions : Nil Bowel/ bladder: regular bowel movements Allergies: nil GENERAL EXAMINATION: Conscious coherent cooperative  Moderately built Moderately nourished  No pallor   No Icterus   No Cyanosis  No clubbing of finger  No lymphadenopathy Pedal edema with pain present while sitting for long time about 30 min,then it was relive  by walking ,it was present from past  6
Read more