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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