GENERAL MEDICINE ELOG.

Hi,I am Mattupalli Pritish Jasper 3rd semester 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 




















Comments

Post a Comment

Popular posts from this blog

GENERAL MEDICINE ELOG

Image
 Hi, I am, Mattupalli Pritish Jasper(roll no:69), a 3rd semester medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent. This also reflects my patient-centred care and online learning portfolio. A 73 yr old male patient who is a farmer by occupation came to casualty with shortness of breath Case sheet: Chief complaints: The patient complained of severe breathlessness since 10days and epigastric pain since 4days  History of present illness The patient was apparently asymptomatic 12yrs back.Then he developed chronic cough for which he went to a hospital where he was diagnosed with Tuberculosis then he used medication for 6months  Then 4yrs back the patient developed a swelling in the scrotum which was diagnosed as hydrocele and then the surgery was done. Since 2months the patient is having breathlessness and used medicines given by the local doctor.He used to drink alcohol to get sleep at night. 1day back he developed a
Read more

GENERAL MEDICINE ELOG.

Image
Hi,I am Mattupalli Pritish Jasper 3rd semester 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 35 year old female came to OP with fever and weakness   Chief complaints: The patient complained of severe breathlessness since 10days and epigastric pain since 4days  History of present illness The patient was apparently asymptomatic 3 months back.Then he developed fever and chills for which he went to a hospital where he was diagnosed with mild grade anemia then he used medication for 1 month.  Then 1 month back the patient developed heavy fever and weakness and dyspnea on exertion. Since 1 weak the patient developed SOB.  1day back she developed a grade 4 SOB then he was brought to the hospital  History of past illness: The patient is not a known case of diabetes,asthma,epilepsy and hypertension  Personal history: Diet- mixed Appetite- normal Sleep- decreased  Bowel Mov
Read more

Medicine ELOG.

Image
Hi,I am MATTUPALLI PRITISH JASPER  3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.       Cheif complaints: A 46 years old female who is a agricultural labour came with c/o SOB exertion since one week c/o abdominal distension since last week patient was apparently asymptomatic one year back and then devoloped dyspepsia for which she started using tablets on and off and was fine after taking tablets then she devolped SOB since one week which was not associated with chest pain and palpitations HOPI: Pedal edema , cough . patient noticed a swelling in epigastric region during exertion and she also devolped abdominal distension since one week  no h/o of cough ,cold and fever   History of past illness : No h/o chest pain,palpitations and PND No h/o headache  No h/o burning micturition  N/K/C/O HTN , DM ,TB , epilepsy ,asthma Personal history : normal apetite Bowels :
Read more