GM case

August 27,2022

Case scenario.......

Hi, I am P. Prajwala , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:A 43 old man presented with shortness of breath, orthopnea, PND and decreased output since one month 

HISTORY OF PRESENT ILLNESS:Apparently asymptomatic one month ago and developed SOB , orthopnea and decreased urine output 

ASSOCIATED DISEASES:Diabetes mellitus, hypertension 

PAST HISTORY:Post CPR status revived 

K/c/o diabetes mellitus since 10 years

K/c/o HTN since 3 years

PERSONAL HISTORY:Appetite normal , mixed diet ,bowels regular, mituration normal , no known allergens, no addictions

FAMILY HISTORY:

No prominent history 

DRUG HISTORY:Diabetes mellitus 

Hypertension 

CAD

GENERAL EXAMINATION:>Pallor : Present

>Icterus : Not seen

>Cyanosis : Not seen

>Clubbing : Not seen

>Lymphadenopathy : Not seen

>Edema : B/L Pedal edema seen

VITALS:

Temperature: 98.6

Pulse88 beats per minute

Respiratory rate:14 cycles per minute

Blood pressure:110/70mm of Hg

SPO2:98

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills

No murumurs

Cardiac sounds: S1, S2 ____

Respiratory system:

No dyspnea

No wheezing

Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid

No tenderness

No palpable mass

Non palpable liver

Non palpable spleen

No bruits

Bowel sounds: heard

Central Nervous System:

Conscious

Speech: normal

INVESTIGATIONS:

Biochemical investigations:

  

PROVISIONAL DIAGNOSIS:CKD on MHD

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