gm case 4

CASE SCENARIO 

I am Sahithi, 3rd BDS student.

This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

Patient details:

45 yr old male resident of nalgonda 

Chief complaint:

Swelling of legs from 2 months 

Decreased in urine output

Shortness of breath from 7 days 

HOPI:

Patient was apparently asymptomatic 1 week back then he started complaining of pedal edema pitting type extending till knees along the decrease in urine output and sob grade 2 

History of past illness:

Diabetes-7 yrs

Hypertension-9months 

Tuberculous-5 yrs 

Personal history:

Diet: mixed

 Appetite:normal 

bowl:normal

Addictions-no 

Allergies-no 

 

Family history - not significant

General examination:

Pallat- yes 

Icterus-no

Clubbing- no

Kyphoscoliosis-no

Lymphadenopathy-no

Edema-yes

Pulse rate- 84/min 

Temperature-98. 8

Bp- 130/80

Systemic examination:

Inspection:

Chest symmetry-bilateral 

Shape of chest -elliptical

Kyphoscoliosis-no

Bilateral viens-no

Scary-no

Palpation

Local temperature- normal

Tenderness-no

Pulsation-yes

impulse-normal 

Kyphoscoliosis-no

Percussion

Dull 

Auscultation - dull