General medicine case discussion

 JANUARY 3RD

3/1/2023
General medice elog

Hi , I am M Sumanth Reddy of 3rd semester 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. 



CHEIF COMPLAINTS 

A 75year old male who is farmer by occupation  came to OPD with cheif complaints breathlessness and swelling in legs since 1 month.

HISTORY OF PRESENT ILLNESSES 

Patient was apparently asymptomatic one month ago.Then he had slowly increasing breathlessness,and developed pedal edema. There is history of cough which is productive(sputum). There is no h/o of fever, burning micturition, decreased frequency of micturition, chills and rigor.

PAST HISTORY 

No history of Diabetes ,BP 

No history of Asthma,TB,CAD,Epilepsy 



FAMILY HISTORY


No history of Diabetes ,BP 



PERSONAL HISTORY

Mixed Diet 

Appetite- normal

Sleep adequate

Bowel and bladder movements-normal 

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

Pedal edema present 



VITALS:
Heart rate:60bpm
Respiratory rate: 19 per min
Blood pressure: 170/100 mmHg

HEMOGRAM:-



URINE EXAMINATION:-




TREATMENT:-
1.Inj Lasix 20mg
2.Inj .NaHCO3 50Meq
3.Tab Nodosis 500mg
4.Tab.Shelcal 
5.Tab. OROFER-XT
6.Inj. Erythropoietin 4000IV
PROVISIONAL DIAGNOSIS:-   Acute on CKD

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