General medicine

 JANUARY 3RD

3/1/2023

General medice elog

Hi , I am G Manish Reddy of 3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio. 

CHEIF COMPLAINTS 

A 85 year old male who is farmer by occupation resident of achampeta came to OPD with cheif complaints of breathlessness while walking,fever, swelling in the legs.

HISTORY OF PRESENT ILLNESSES 

Patient was apparently asymptomatic  15 days ago.Then he had slowly increasing breathlessness,(he developed SOB initially grade 2 later progressed to grade 4,incidious onset not associated with diurinal variation and also varies with posture).which was initially less but gradually increased.mild fever(intermittent type) has also developed And there was also sweeping in the feet of Patient .

Pedal edema(incidious onset whic was progressed from grade 1 then grade 4,which was increased while working and decreased during rest).

He previously visited RMP and took medication.where his symptoms did not decreased.

PAST HISTORY 

No history of Diabetes ,BP 

No history of Asthma,TB,CAD,Epilepsy 

FAMILY HISTORY

Has a familial history of BP, to his mother in law and even wife.

PERSONAL HISTORY

Mixed Diet 

Appetite- normal

Sleep adequate

Bowel and bladder movements-normal 

drinker since past 50 yrs

Even has habit of smoking(beedi) from past 30 yrs.

But stopped due to symptoms

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

Pedal edema present 

Irregural deformation of fingers

VITALS:

Heart rate:60bpm

Respiratory rate: 19 per min

Blood pressure: 170/100 mmHg

HEMOGRAM:-

LIVER FUNCTION TESTS:-

COMPLETE URINE EXAMINATION:-

TREATMENT:-

1.Tab Lasix 40 mg

2.Inj .Epo 4000iv weekly once

3.Tab Nodosis 500mg

4.Tab.Shelcal 500mg

5.continue the medication for asthma