General Medicine E-log (6)

Hi, I am Danush Varkur, 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 Complaint:
A 60yr old male from Valigonda came to OPD with chief complaints of
Puffiness of face since 1week
Bilateral edema of upper and lower extremities since 1week

History of presenting illness:
Patient was apparently asymptomatic 12yrs ago, then he developed Hypertension for which he is taking medication. After 8yrs, he developed diabetes mellitus for which he has been taking medication. Then, 4yrs ago, he developed high grade fever associated with dry and scaly legs associated with pain which was severe and he was unable to walk properly because of that. Then, he went to a local hospital where he was diagnosed with filariasis. He was given medication, which he followed regularly due to which his pain subsided. Then, 1 week ago he developed puffiness of his face and bilateral edema of both hands and limbs which was of pitting type and was not associated with any aggravating or relieving factors. He also complains of dyspnea of grade 3 since 1week which was aggravated by minimal exertion and relieved by resting. Patient complains of platypnea as well.

Past history:
Patient is a known case of Hypertension, Diabetes mellitus, Asthma
N/K/C/O TB, Epilepsy, CVD 

Personal history:
Diet: mixed
Appetite: Normal
Sleep: Adequate
Bowel and bladder movements: normal
No burning micturition
Addictions: Alcoholic for more than 35yrs
                     Smoking- stopped since 5yrs

Allergic history:
Not significant

Drug history:
History of medication for Hypertension, Diabetes mellitus and filariasis

Family history:
No significant history


General Examination:
Patient is coherent, co operative, comfortable and well oriented to time, place, person
Moderately nourished
Pallor- absent
Icterus- absent 
Cyanosis- absent
Clubbing of fingers- absent
Lymphadenopathy- absent
Edema- present on upper and lower extremities 

Investigations:
Provisional diagnosis:
Left ventricular heart failure

Comments

Post a Comment

Popular posts from this blog

General Medicine E-log (3)

Image
Hi, I'm Danush Varkur (roll:29), 3rd sem medical student. This is the online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. CASE SHEET:- Chief complaint; A 29yr old female, resident of Mumbai, customer service executive by occupation came to OPD with chief complaints of Increased sweating 4days ago Shortness of breath 4days ago  Dizziness 4days ago Vomitings 2episodes/day before the day of admission  History of present illness; Patient was apparently asymptomatic 5yrs ago. Then she developed ulcers in mouth and painless rash on her face across her nose, hair loss and sensitivity to light on her face.Then she went to a private hospital where she was referred to another doctor where she was diagnosed with SLE. She was given medication for it. Then, 1 month ago, she developed Shortness of breath and went to hospital where she was diagnosed with kidney disease. She was
Read more

General medicine E-log (2)

Image
Hi, I'm Danush Varkur (roll:29), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio. CASE SHEET: Chief Complaint; A 50r old patient who is farmer by profession came to OPD with the chief complaint of decreased urine output, swelling of legs for the past 8 months History of present illness; Patient was apparently asymptomatic 8months ago. Then he developed oedema of legs and hands with decreased urine output with burning micturition and developed fever. He visited the local doctor for the problem and the local doctor sent him to the hospital for further evaluation. On checkup, he was diagnosed with a kidney infection. He has been on dialysis 2days per week for 4hrs for the past 8months. He also has cough for which he consulted the doctor. For which they tested and found to be normal but the cough still persisted. Daily routine: P
Read more