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