general medicine blog 6
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio .
Name : G sravanthi
Roll no :41
2020 Batch.
A 65 years old male came to OPD with
Chief complaints of: swelling in abdomen and cough since 10 days
History of present illness: patient was asymptomatic 10 days ago later he developed swelling in abdomen and break in urinary stream and he also had cough since 10 days and he has swelling in the region of neck since 10 years with this symptoms he visited nalgonda govt hospital he adviced to visit Kim's for dialysis
Past history
No diabetes mellitus
No hypertension
No asthma
No TB
No known allergies
Family history
No family history'
PERSONAL HISTORY:
Marital status: married
Occupation: farmer
Appetite: normal
Diet: mixed
Bowel : regular
Micturation: abnormal
Addictions: alcoholic and smoker 20 years back
GENERAL EXAMINATION:
Conscious, coherent, co-operative Moderately built, nourished.
PALLOR: ABSENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
EDEMA Of FOOT : PRESENT
VITALS
TEMPERATURE: 98.7 F
PULSE RATE:840beats /min
RESPIRATORY RATE: 28 Cycles/min
BP:180/100mm of hg
SPO2:98% at room air
SYSTEMATIC EXAMINATION
CVS:
S1,S2 Sounds heard
RESPIRATORY SYSTEM:
Dyspnea is absent
Wheeze is absent
Position of trachea:central
Adventitious sounds : crepts present
ABDOMINAL EXAMINATION :
INSPECTION:
abdomen : obese
Palpation
No local rise of temperature
Tenderness present
No Palable mass
Liver and spleen not palpable
Percussion
Free fluid present
Ascultation
Bowel sound are heard
INVESTIGATION
Grade2 rapid pelvis dilation in bilateral kidneys with bilateral cortical cyst
