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









Comments

Post a Comment

Popular posts from this blog

Gen med elog

Image
  35YR MALE WITH C/O ABDOMINAL SWELLING This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs . A 35 year old male house contractor by occupation from Miryalaguda came to general medicine OPD with chief complaints of swelling in feet and abdomen since 2days  Tingling sensation,cought since 1 week , difficulty in intake of food. History of presenting illness:  Patient was apparently asymptomatic 2days back then he developed edema in lower limbs  which is  insidious in onset gradual in progression  and pitting type? and then he developed  swelling in abdomen insidious  onest gradual progression h/o nausea ,tiredness and tingling sensation after eating food 
Read more

GENERAL MEDICINE ASSESSMENT

Image
   M easha chandrika    Rollno:76    Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data                                            this e log is made under the guidance of Dr.kranthi mam [intern] CASEHISTORY: 18 yrs old patient came to casuality  CHIEF COMPLAINTS;   weakness of both Lower limbs and was unable to stand and walk HISTORY OF PRESENT ILLNESS: ▪︎weakness of lower limbs  ▪︎unable to stand  ▪︎unable to walk HISTORY OF PAST ILLNESS: ▪︎H/o seizure episodes  ▪︎unable to walk till 6 yrs  ▪︎difficulty in studying and writing till  6yrs ▪︎she went for urination and suddenly she couldn't getup on her own she was taken to hospital and was diagnosed hypokalemia  ▪︎she took herbal medication later she developed nausea and vomitings and was taken to hospital and later she was diagnosed Dyselectrolytemia ▪︎then after she developed spasm of upper limbs ▪︎pedal edema (grade 1) 2months back                             
Read more

Gen med blog :fever and cough with sputum

  This is case of 83yr old male came with complaints of cough with sputum since 4 days,breathlessness since 4 days. Patient was apparently asymptomatic 4days back then he developed  cough which was insidious in onset, gradually progessive associated with sputum which was white in colour ,copious  amount. Fever since 4 days,high grade, associated with chills and rigors Breathlessness since 4 days which was insidious in onset , gradually progressive from grade 2 to grade 4 No h/o chest pain, orthopnea,pnd, palpitations,pnd PAST HISTORY: Patient is not a known case of Hypertension, Diabetes mellitus, TB, Epilepsy, Bronchial asthma, Thyroid disorders PERSONAL HISTORY: Diet - Mixed Appetite - decreased Sleep - Adequate Bowel and Bladder movements- Regular Addiction - consumption of alcohol occassionally,h/o smoking since 30 yrs (1pack per day) GENERAL EXAMINATION  Patient is conscious, coherent and cooperative and well oriented to time, place and person He is moderately built There is prese
Read more