general medicine

Hello all this is G Pranay kumar rao,a fifth semester student.This E Log depicts the patient centered approach to learning.

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

A 65yr old male came to clinical opd with 
Chief complaints 
 • Pedal edema since 1month
 • decreased urine output
 • SOB
 • burning micturition
 • decreased appetite
 • low grade fever
 • generalized weakness

History of presenting illness
Patient was apparently asymptomatic 1yr back ,then he developed knee pains and there was difficulty in walking ,so he was taking NSAIDS  regularly.
Then he developed bilateral pedal edema since 1month and he is unable to strech his legs and he had burning micturition and decreased urine output and also generalized weakness .


History of past illness
k/c/o diabetes mellitus since 1yr 
and Hypertension since 1yr and on medication
Treatment history 
 • He was on nsaids for knee pains 
 • And he was taking metformin and antihypertive medication

PERSONAL HISTORY
 • Mixed diet ( Mostly rice and pickles)
 • Decreased appetite since 4days 
 • Regular bowel
 • no known allergies 
 • adequate sleep
 • habits- occational alcohol consumer ,but stopped since 5months 

 • DAILY ROUTINE
1year back- He used to get up at 6:00 and have rice for breakfast and then go for daily wage work and at afternoon at 2:00pm he would have rice (mostly with pickles) for lunch and would come back home around 6:00pm  and would get freshen up and have his dinner (rice) and would go to sleep.

GENERAL EXAMINATION
 • Patient is conscious,coherent,co - operative and well Oriented to time,place and person.
 • There are no signs of pallor cyanosis,lymphadenopathy ,icterus,clubbing
 • There was bilateral pedal edema since 1month

Vitals
Temperature-afebrile
PR-82BPM
BP-150/90mmhg
RR-14/min

SYSTEMIC EXAMINATION
CVS
S1 AND S2 heard
no thrills
no Murmurs

RESPIRATORY
no dyspnoea
no wheeze
Trachea is centrally located
vesicular breath sounds

ABDOMEN
scaphoid shaped abdomen
no tenderness
no palpable mass
bowel sounds heard

CNS
NAD

INVESTIGATIONS

PROVISIONAL DIAGNOSIS
CRF 2° TO ? NSAID ABUSE 
WITH GRADE 1 PROSTAMEGALY

TREATMENT 
3/8/22
 • Salt and fluid restriction
 • Tab.Lasix 40mg po/bd
 • Tab.NODOSIS 500mg po/bd
 • Tab.SHELCAL500mg po/bd
 • Cap. BIO-D3 PO/weekly once 
 • GRBS -6th hourly
 • Syrup-Aristozyme 15ml po/tid
Tab.Ultracet 1/2 po /qid 

4/8/22

 • Salt and fluid restriction
 • Tab.Lasix 40mg po/bd
 • Tab.NODOSIS 500mg po/bd
 • Tab.SHELCAL500mg po/bd
 • Cap. BIO-D3 PO/weekly once 
 • GRBS -6th hourly
 • Syrup-Aristozyme 15ml po/tid
 • Tab.Ultracet 1/2 po /qid 
 • TAB.TAMSULOSIN D-0.4mg po/hs
 • Tab.NICARDIA 10mg po/bd

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