Male patient of 65 yrs old came to opd with complaints of shortness of breath since 1 year, bilateral pedal edema since 1 week and diarrhoea and fever since 4 days.

 Hi, I am Presley Chavadi (Roll No. 96), 3rd semester medical student. This is an online e-log book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

CHIEF COMPLAINTS

The patient of 65 years came to hospital 4 days back with complaints of shortness of breath since 1 year, bilateral pedal edema since 1week and diarrhoea and fever since 4 days.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 year ago when he developed shortness of breath, which is exacerbated by physical activity and also present at rest. Developed bilateral pedal edema since 1 week, pitting type. Also had episode of diarrhoea 4days ago associated with fever.

History of past illness

Had undergone laparotomy for appendicitis 30 years back.
Known case of Chronic kidney disease since 2 years.Known case of hypertension since 2 years.
On medication: T.Prazosin 10mg ,T.Arkamine 0.1mg, T.Clinidipine 10mg


4. TREATMENT HISTORY 

  • Diabetes - No
  • Hypertention - Yes
  • CAD - No
  • Asthama - No 
  • Tuberculosis - No 
  • Antibiotics - No 
  • Hormones - No
  • Chemo / Radiation - No 
  • Blood Transfusion - No / Yes, 
  • Surgeries - Yes, Details:Abdominal Surgery Lapotomy
  • Other 

PERSONAL HISTORY 

Occupation daily wage worker

Married

Diet:mixed

Appetite:normal

Sleep:normal

No known allergies

FAMILY HISTORY 

 Diabetes - No

Hypertension -yes

Heart disease - No

Stroke - No 

Concern - No

Tuberculosis-no

Asthma - No


General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

Pedal edema is seen





SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills: No 

2. Cardiac Sounds : Heart sounds 

3. Cardiac murmurs: No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - yes

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices: Normal 

5. Free Fluid: No 

6. Bruits: No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

Central nervous system 

1.Level of conscious conscious and cohertness: normal

2.Speech: normal

3.Sign of meningeal irrigation

Neck stiffness: no

Kerning sign: no

4.Cerebral signs

Finger nose test: in coordination 

Knee heel test: in coordination 

Investigation 

Provisional diagnosis:Chronic kidney disease

Treatment: MHD 


















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