GM-2

Hi 

I am soumya donthi (roll no 31)3rd sem medical student. This is an online elog book to discuss our patients health data after taking his consent .This also reflects my patient centered online learning portfolio.

Chief complaint -

A 46yr old male patient who is farmer by occupation came to OPD with the chief complaint of swelling of lower limbs.

History of present illness-

Patient was apparently asymptomatic 10 days ago.

Patient is suffering with swelling of lower limbs and distended abdomen which is not associated with pain since 10 days.

Patient is also having low grade intermittent fever not associated with chills .

Patient was admitted in the hospital on 18/6/22

But the urinary output is reduced since 2 days.

From yesterday the condition of patient was better with increased urinary output.

Past history -

Patient is a known case of Diabetes

No TB

No CAD

No Epilepsy

No Asthma

Personal history-

Diet: mixed

Appetite: normal

Bladder/ Bowel movements: decreased urine output

Sleep: adequate

Addictions:  alcohol- occasionally 

Allergic history-

No known allergies

Drug history-no drug history

Family history-

No known cases in family

PHYSICAL EXAMINATION-

General Examination:

Patient is conscious, coherent, comfortable 

Moderately built

Pallor is present

No icterus

No cyanosis

No general lymphadenopathy

No clubbing of fingers

Pedal oedema seen 

Vital signs-

Temperature: 97.8°F

Pulse: 88bpm

BP: 130/90

Respiratory rate: 16cpm

SpO2: 96%

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 obese

No tenderness

No palpable mass

Non palpable liver and spleen

INVESTIGATIONS DONE;

Hemogram

Serum electrolytes

Serum creatinine

Blood urea