General medicine case-3

  This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

CHIEF COMPLAINT:

A 45 years old male who is  daily labour by occupation came to OPD  with the chief complaint of pedal edema, abdominal distension and since 3 days with chest pain.


HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic but then he was having fever,vomitings,loose stools and pain in the abdomen.

HISTORY OF PAST ILLNESS:

Since 6 years he was a hypertension patient and from 2 years back he was diagnosed with CKD and 4 months back he was tested positive for covid and had never undergone any surgeries.

PERSONAL HISTORY:

Marital status- married.

Appetite- normal.

Diet- mixed .

Bowel movement- regular.

Mituration- regualr.

Habits -Drinks alcohol and takes tobacco but he stopped 4 months back.

FAMILY HISTORY:

There is no family history.


PHYSICAL EXAMINATION:

GENERAL

Palar- yes 

Cynosis- no.

Icterus- no.

Lymphadenopathy- no.

Clubbing of fingers and toes- no.

Malnutrition- no.

Dehydration- no.

Oedema- yes.

VITALS

Temperature:98.4F

Pulse rate:84/min.

Respiratory rate:24/mm.

BP:140/100mm

SpO2 at room temperature:98%

GRBS:126 mg%.


SYSTEMIC EXAMINATION:

Cardiovascular system

Thrills- no.

Cardiac sounds - S1 and S2 heard.

Murmurs - no.


Respiratory system.

Dyspnoea- no.

Wheeze- no.

Position of trachea- center.

Breath sounds- vesicular.


Abdomen

Shape- soaphoid.

Tenderness- no.

Palpable- no.

Free fluid- no.

Bruits- no.

Liver- not palpable.

Spleen- not palpable.

Bowel sounds- heard.


CNS.

Consciousness- alert.

Speech- normal.

Neck stiffness- no.


TREATMENT HISTORY:

Diabetes- no.

Hypertension- yes.

CAD- no.

Asthma- no.

Tuberculosis- no.

Antibiotics- no.

Hormones- no.

Blood transfusion- no.

Surgeries- no.














































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