A 55 year old male with SOB and pedal edema.
July 18,2023
USG:
Hi,I am Athram Divya Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
CHIEF COMPLAINTS:
A 55 year old male patient resident of madhavagudem came to OPD with chief complaints
-SOB since 15 days
-pedal edema since 1 week
HOPI:
Patient was apparently asymptomatic 15days back then he developed SOB (grade 1and2) that was insidious in onset, gradually progressive
C/o pedal edema since 5 years and aggravated since last 15 days it is a pitting type
C/o decreased urine output since 1week
No C/O chest pain, palpitations, orthopnea, PND.
No H/O fever, burning micturition, loose stools, vomiting.
No C/O pain abdomen.
PAST HISTORY:
N/K/C/O HTN,DM epilepsy , TB ,thyroid disorder
K/C/O CKD diagnosed 1month back
PERSONAL HISTORY:
Diet - Mixed
Appatite - Normal
Sleep - Reduced
Bowel and Bladder - Reduced urination, normal bowel.
Allergy - None
Addictions
- Alcohol - about 90ml per day since his teenage.
- Bedi - 1 packet per day since his teenage.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
He is moderately build and well nourished.
Pallor - present
Icterus- present
Clubbing-absent
Cyanosis-absent
Lymphadenopathy-absent
Edema - B/L pitting type present, extending upto the knee.
Vitals:
Temperature -98.6F
Pulse rate - 94/ minute
Respiratory rate - 20/minute
Blood pressure (left arm) - 100/60 mm of Hg
GRBS - 105 mg/dl
Systemic Examination
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
no dyspnea
No wheezing
central trachea
vesicular breath sounds
Abdomen
Scaphoid shaped abdomen
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds -yes
CNS
Patient was conscious
Normal speech
INVESTIGATIONS :
ECG:
