GM-1
July 7 , 2022
I'm Soumya donthi (rollno: 31) 3rd sem 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 centered care and online learning portfolio.
CASE SHEET:
Chief Complaint:
A 70 year old patient who is farmer by occupation came to opd with a chief complaint of pedal edema since 10 days
History of present illness:
Patient was apparently asymptomatic 10 days then he developed pitting type of pedal edema upto ankle.
History of past illness;
Patient is a known case for Hypertension since 2 months
No diabetes
No TB
No CAD
No Epilepsy
No Asthma
Past history:
No past history
Personal history;
Diet: mixed
Appetite: normal
Bladder/ Bowel movements: regular
Sleep: adequate
Addictions: alcoholic occasionally
Allergic history;
No known allergies
Drug history;
No drug history
Family history;
No relevant family history
PHYSICAL EXAMINATION;
General Examination:
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
Pedal edema present
Vital signs;
Temperature: 98.6 F
Pulse: 90bpm
BP: 130/80
Respiratory rate: 16cpm
SpO2: 98%
Systemic Examination;
Cardiovascular system:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs
Respiratory system:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds
Abdomen:
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are heard
INVESTIGATIONS DONE;
RBS
2D ECHO
Hemogram
Chest xray
RFT
serum albumin
Serum iron
CVE
Provisional diagnosis;
Chronic Kidney failure on MHD
What are we doing? (Treatment)
The patient is undergoing dialysis as said 2 times a week from 2 months along with some medication.
Medication
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