General medicine case discussion

 Hi, I am M. Sumanth Reddy (Roll no:64) 5th sem medical student. this is an online elog book to discuss our patients health data after taking their consent.This also reflects my patient centered online learning portfolio.


A 30yr old male came to the hospital with complaints of weakness 


Chief complaints:


The patient came to the hospital on tuesday with chief complaints of weakness and shortness of breath


History of presenting illness:


The patient was apparently asymptomatic 1yr ago then he visited a local hospital with complaints of weakness and pain at the lumbar region,then dialysis was recommended at the local hospital,for dialysis he visited Gandhi hospital,medications were given 6 months and told to stop alcohol and meat.he took medications for 1 month and and then stopped,he also started consuming alcohol.Then he visited Kims hospital 6 days ago with complaints of shortness of breath.


Negative history:


Fever- No history of fever


Shortness of breath: history of shortness of breath 


Past history:


No significant past history 


Personal history:


Married


Occupation: labourer


Diet:mixed


Bowel movements:Normal


  addictions:alochol(regular)


Apetite: decreased 


Sleep:Normal


No known allergies


Hemogram




General examination:


Conscious


Coherent 


 UnCooperative 


No pallor


No icterus


No cyanosis


No clubbing of fingers


No lymphadenopathy 


Pedal edema:No


Complete urine examination




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