GEN MED E-log Aug-06

 E-LOG GENERAL MEDICINE

Hi, This is Vaishnavi, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

A 66 YEAR OLD WITH END STAGE RENAL DISEASE

Chief complaints:

A 66 year old male hailed from suryapet presented to the OPD with chief complaints of:

Bilateral pedal edema since 3 months.                          SOB since 3 months.                                              Puffiness of face.                                                        Body aches

HOPI:

Patients was apparently asymptomatic 12 years ago .

He developed chest pain and was diagnosed with IHD: S/P CABG was done.

At the same time he was diagnosed with hypertension and DM 2 for which he started taking medicine.

Then he was fine till 3 months back and started developing B/L pedal edema which is pitting type and was extended up to knees and Grade 2-3 SOB.

He went to hospital and was diagnosed with kidney disease .

Then he was planned for hemodialysis with right IJV.

1st dialysis on-23/07/22

2nd dialysis on-24/07/22

Loss of weight about 15kgs since 2 months

PAST HISTORY:

DM since 12 years.                                                    HTN since 12 years.                                                   SOB

FAMILY HISTORY: Nil significant

PERSONAL HISTORY:

Mixed diet

Appetite-normal

Sleep-inadequate 

Bowel and bladder habits-normal

No allergies

No addictions

GENERAL EXAMINATION:

VITALS:

Patient was conscious and coherent

Well built

Temp:afebrile

Pulse rate: 72 bpm

RR: 14 cpm

BP: 110/70

Spo2: 99%

GE:

•No pallor/icterus/clubbing/cyanosis/lymphadenopathy

Course in hospital:

ECG at presentation



 




                         Ultrasound report



              CBP

            


                   URINE EXAMINATION

 


                         RFT


             TREATMENT




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