E-LOG GENERAL MEDICINE
Hi, I'm 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
Case scenario
Chief complaints-
A 65 year old male, farmer by occupation came to OPD with the chief complaintsof -
SOB since 2 months
Loin pain since 2 months
History of presenting illness-
Patient was asymptomatic 2 months ago and then he gradually developed SOB grade 2 which is aggravated on exertion and relieved on rest and medication
He also developed loin pain which was also relieved on medication and rest
History of past illness-
K/c/o DM since 1 year
K/c/o Hypertension since 3 years
Personal History-
Married
Vegetarian
Bowel movements regular
Micturition normal
No known allergies
FAMILY HISTORY
Also has a history of DM and Hypertension
GENERAL EXAMINATION
- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing
- BP - 120/60 mmg
- PR - 70 /min
-RR- 22 /min
- SPo2 -98% at RT
- Temp - 97 degree F
SYSTEMIC EXAMINATION
— CVS
- Thrills : No
- Cardiac sounds - S1 , S2 heard
- Cardiac murmurs : No
— RS
- Dyspnea : yes
- Wheeze : yes
- Position of Trachea : central
- Breath sounds : vesicular
— ABDOMEN
- Shape of abdomen : scaphoid
- tenderness not present , no palpable mass
- Hernial orrifices : Normal
- No fluids
- Liver and Spleen are not palpable
- Bowel sounds : yes
— CNS
- patient is conscious
- speech is normal
- No signs of meningeal irritation
- Higher motor functions intact
Investigations -
Ultrasound report-
Treatment history -
Seven sessions of hemodialysis were complete and the last session was on 24/08/2022
Treatment-
30/08/2022
31/08/2022
1/09/2022
