B . Sravani 15

Sravani 15 
June 25, 2022


                   GENERAL MEDICINE. 


25 June,2022

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


                      CASE REPORT 
 A 59 year old male with chief complaints of pedal edema, shortness of breath, oliguria . 


CHEIF COMPLAINTS: 
Bilateral pedal edema since 1year
Oliguria since 3months 
SOB since 3 months on excertion. 


HISTORY OF PRESENT ILLNESS: 
Patient was normal 1 year back  then he developed pedal edema which is bilateral pitting type .
He had pain in chest region. 
Shortness of breath during walk. 
Urine output is decreased. 

HISTORY OF PAST ILLNESS: 

N/K/C/O HTN, DM, CAD, TB, Asthma

TREATMENT HISTORY: 
Nothing significant

PERSONAL HISTORY:
Married. 
Appetite - normal 
Non vegetarian 
Bowels- regular. 
Micturition- abnormal 
Known allergies - none 


FAMILY HISTORY : 
Nothing significant

PHYSICAL EXAMINATION:

GENERAL:

No signs of pallor, icterus, clubbing of fingers or toes, malnutrition.  

Oedema of feet - yes

VITALS: 
Temp- a febrile
Pulse rate -80 bpm
Respiration rate-16 per min
Bp- 130/90mmhg
Spo2: 98 

SYSTEMIC EXAMINATION: 
CVS: S1S2 ++ 

RESPIRATORY SYSTEM: 
Dyspnoea - yes
Position of trachea - central 
Breath sounds - vesicular 

ABDOMEN : 
Shape of abdomen - scaphoid 
Tenderness - no 
Palpable mass- no 
Hernial orifices - normal 
Free fluid - no 
Bruits- no 
Liver-  palpable 
Spleen - not palpable. 
Bowel sounds - yes. 

CNS: 
Level of consciousness- conscious 
Speech- normal 
Signs of meningeal irritation- none 

INVESTIGATIONS:
RFT
HEMOGRAM
BLOOD SUGAR -
LFT
ECG

 PROVISIONAL DIAGNOSIS: 
CKD

TREATMENT: 
1)Tab. Lasix 40mg/po/OD
2)Tab. MVT/po/OD.



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