GM -07

25 July 2023


Hi , I am Shivani Veerabrahmam 3rd year dental student . This is online elog book to discuss my patient health data shared after taking his/her constent . This also reflects my patient centered online learning portfolio .

The patient’s consent was taken verbally prior to history taking and examination of his/her condition. 

CASE SHEET: A 55 year old male resident of Halia came with a chief complaint of pedal edema.

CHIEF COMPLAINTS : Pedal edema ,Shortness of breath.

HISTORY OF PRESENT ILLNESS: 
Patient was apparently asymptomatic one month ago then he developed weakness and pedal edema. Pedal edema was of pitting type.
Shortness of breath since 5 days which is of grade II and gradually progressive .
Patient also had vomitings from past 3 days 2 to 3 times a day,which is non bilious and non projectile.
Productive cough from 5 days intermittent during night time.
Not associated with abdominal pain ,loose stools 

HISTORY OF PAST ILLNESS:
No history of Hypertension, Diabetes Mellitus,Asthma ,etc

PERSONAL HISTORY:
Single/married: Married
Occupation :Farmer
Appetite :loss of appetite 
Veg/Non-Veg: Mixed
Bowels : Irregular 
Micturition : Decreased 
Known Allergies :Nil
Habits/Addictions :Alcohol

FAMILY HISTORY :Nil


GENERAL EXAMINATION : 
Pallor :Yes
Icterus :No
Cyanosis :No
Clubbing of fingers/toes :No
Lymphadenopathy :No
Oedema of feet :Yes
Malnutrition :No
Dehydration :No

VITALS :
Body temperature : 96.2F
BP : 100/80 mm/Hg
Pulse Rate : 88/min

SYSTEMIC EXAMINATION :
Respiratory System:
Nasal Septum - no deviation
Nasal polyps - absent
Position of trachea - central
No drooping of shoulders
Abdomen :
Shape of abdomen - Scaphoid
Tenderness -No
Palpable masses -No
Palpable liver - No
Palpable Spleen - No

PROVISIONAL DIAGNOSIS:
Renal failure

Q/A 
1. What is the possible treatment options ?
2. Can the condition be reversible ?












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