General medicine
- 107 Sujeeth
Under the guidance of Dr. Vamshi(PG)
This is an online e-log platform to discuss case scenario of a patient with their guardians permission.
I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings ,investigations, come up with a diagnosis and treatment plan.
Date of admission:-05/10/2021
Case scenario:-
A 46 year old male patient came with the complaints of shortness of breath since five days, profuse sweating, generalized weakness and pedal edema.
Chief complaints:-
-Pedal edema ,pitting type
-Facial puffiness since 10 days
-Upper limb edema
-Shortness of breath
History of present illness:-
Patient was apparently asymptomatic one month back then developed pedal edema which was gradually progressive associated with shortness of breath.
No history of burning micturition.
No history of decreased urine output.
No history of Orthopnea PND.
History of past illness:-
Known case of Diabetes Mellitus since 11 years(on regular medication tab.Voglibose,tab.Gliclazide)
Known case of Hypertension since 3 years.
Personal history:-
Diet-mixed
Appetite-lost
Bowels-regular
Micturition-normal
Has no known allergies
Alcohol-occasionally
Non smoker
Family history:-
No h/o same complaints in family. No abnormality detected.
General examination:-
Patient c/c/c well oriented to time, place, person.
Moderately built, well nourishment.
VITALS
Pulse rate-96 beats/min
Respiratory rate-24/min
BP-140/90 mm/Hg
Temperature-Afebrile
Physical examination-
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing of fingers/toes-absent
Generalized Lymphadenopathy-absent
Edema of feet-present, pitting type
Systemic examination:-
CARDIOVASCULAR SYSTEM-
S1 S2 Heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM-
Vesicular breath sounds heard
Trachea centrally in position
No wheezing
Tachypnoea present
ABDOMEN-
Scaphoid shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
Liver and spleen are not palpable
No bowel sounds heard
CNS-
Conscious and normal speech
Normal gait
Cranial nerves normal
Sensory system normal
Motor system normal
INVESTIGATIONS-
On 5/10/21
On 7/10/21
Tab.Lasix 40 mg PO/BD
Tab.Gliclazid 50 mg PO/OD
Tab.Voglibose 0.2 mg PO/OD
Tab.Met XL 25 mg PO/OD
Tab.Almong 5 mg PO/OD
Tab.Oroter XT PO/BD
Tab.Pan 40 mg PO/OD
Tab.Nodosis 500 mg PO/BD
On 8/10/21
Tab.Lasix 40 mg PO/BD
Tab.Gliclazid 50 mg PO/OD
Tab.Voglibose 0.2 mg PO/OD
Tab.Met XL 25 mg PO/OD
Tab.Almong 5 mg PO/OD
Tab.Pan 40 mg PO/OD
Tab.Nodosis 500 mg PO/BD.
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