E-LOG GENERAL MEDICINE
Hi, This is Moovika, 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
Investigations
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