Case history
12 December, 2021 "This is an online e log book to discuss our patient's de- identified health data shared after taking his / her /guardians signed 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 patients clinical problems with collective evidence based inputs. This e log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."
A 39 yrs old male presented to the opd with chief complaints of
1. Pain in the epigastric region
2. Shortness of breath.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back then developed shortness of breath and pedal edema
Patient visited nearby hospital , and was suggested for dialysis.
Patient reported on 24 November 2021 with chief complaints of epigastric pain which was non radiating type and shortness of breath
PAST HISTORY;
Patient is a known case of hypertension since 20 days
No history of diabetes , tuberculosis, seizures , CAD
FAMILY HISTORY;
No significant family history
PERSONAL HISTORY;
Diet- Mixed
Appetite- Normal
Bowel and bladder movement- regular
Patient used to have alcohol occasionally, but stopped after symptoms were expressed
GENERAL EXAMINATION:
patient is conscious, coherent
No icterus
No cyanosis
No clubbing
No lymphadenopathy
VITALS:
Temp- afebrile
BP- 150/90 mm of Hg
Respiratory rate- 22 breathes/min
Pulse rate- 88 bpm
SYESTEMIC EXAMINATION:
CVS:
No thrills
Cardiac sounds S1S2 heard
RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Position of trachea- Central
Breath sounds- vesicular
ABDOMEN-
Shape of abdomen- Scaphoid
No tenderness
No palpable mass
CNS;
Level of consciousness- conscious
Speech- normal
Sensory system motor system- normal in function
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
CKD on MHD with known case of hypertension
TREATMENT:
Fluid restriction
Salt restriction
Tab.Nicardia
Tab. Arkamine
Tab. Lasix
Tab .Shelcal
Tab. Orofer XT
Tab. Pantop
Inj. Erythropoietin
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