GEN MED E-log aug 6

 E-LOG GENERAL MEDICINE


Hi, This is easha chandrika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.


A 66 YEAR OLD WITH END STAGE RENAL DISEASE


Chief complaints:


A 66 year old male hailed from suryapet presented to the OPD with chief complaints of:


Bilateral pedal edema since 3 months.                          SOB since 3 months.                                              Puffiness of face.                                                        Body aches


HOPI:


Patients was apparently asymptomatic 12 years ago .


He developed chest pain and was diagnosed with IHD: S/P CABG was done.


At the same time he was diagnosed with hypertension and DM 2 for which he started taking medicine.


Then he was fine till 3 months back and started developing B/L pedal edema which is pitting type and was extended up to knees and Grade 2-3 SOB.


He went to hospital and was diagnosed with kidney disease .


Then he was planned for hemodialysis with right IJV.


1st dialysis on-23/07/22


2nd dialysis on-24/07/22


Loss of weight about 15kgs since 2 months


PAST HISTORY:


DM since 12 years.                                                    HTN since 12 years.                                                   SOB


FAMILY HISTORY: Nil significant


PERSONAL HISTORY:


Mixed diet


Appetite-normal


Sleep-inadequate 


Bowel and bladder habits-normal


No allergies


No addictions


GENERAL EXAMINATION:


VITALS:


Patient was conscious and coherent


Well built


Temp:afebrile


Pulse rate: 72 bpm


RR: 14 cpm


BP: 110/70


Spo2: 99%


GE:


•No pallor/icterus/clubbing/cyanosis/lymphadenopathy


Course in hospital:


ECG at presentation









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