GENERAL MEDICINE E-LOG
GENERAL MEDICINE E-LOG AUG-07/08/2021
August 07, 2021
06 T KRISHNA HARIKA
(OLD BATCH )
45 YEARS MALE....
AUG 07-08-2021
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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE :
A 45 yr old male , came to the opd with chief complaints of
Pedal edema since 2 month and
Shortness of breath since 2 month
HISTORY OF PRESENT ILLNESS :
Pt was apparently asymptomatic 2 months back later he developed with facial puffiness, shortness of breath and pedal edema since 2 month.
Pedal edema which is gradual in onset,progressive in nature ,pitting type upto knee .
SOB since 1 month - grade 2 dyspnea.
PAST HISTORY :
Not a k/c/o of diabetes ,tb, epilepsy, asthma
k/c/o HTN-1 year.
PERSONAL HISTORY :
Married
Sleep : adequate
Appetite : Decrease, stopped taking non veg food.
Bowel and bladder movements : regular
Alcohol and tobacco consumption:
History of alcoholic consumption: occasional
No history of tobacco consumption
FAMILY HISTORY :
No significant family history
GENERAL EXAMINATION
Physical examination:
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
Pedal edema is noticed which is of pitting type progressive in nature,extending up to the knees
Pallor present
No signs of icterus ,cyanosis , lymphadenopathy, malnutrition, dehydration
Pulse = 82 beats per minute, regular.
- Blood pressure = 140/90 mm of Hg
- Respiratory rate = 18 cycles per minute
-SPO2=98%
-GRBS=109mg%
Systemic Examination:-
CVS:
S1,S2 heard
No Thirlls and murmurs.
RESPIRATORY :
position of trachea-Central.
Breath sounds- vesicular
ABDOMEN:
Shape: Scaphoid.
No tender and palpable mass.
CNS:
Provisonal diagnosis :
Chronic renal failure.
INVESTIGATIONS:
1) ECG:
2)ECHO:
3) REPORT
COMPLE BLOOD PICTURE
COMPLETE URINE EXAMINATION
SERUM IRON
SERUM CALCIUM
PHOSPHORUS
SERUM CREATININE
LIVER FUNCTION TESTS
HBsAg- RAPID
SERUM ELECTROLYTES
ANTI HCV ANTIBODIES- RAPID
BLOOD UREA
EXAMINATION:
1) PALLOR
2) PITTING EDEMA
