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 ?












Popular posts from this blog

GM - 01

February 13 2023 Case scenario…… Hi, I am V.Shivani , 3rd year 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. CASE SHEET : A 83 year old women with chest pain . Chief Complaints : chest pain associated with postural movement (5 days )and shortness of breath. The patient had cough from 3 days but it is irregular. There is no burning sensation . HISTORY OF PRESENT ILLNESS : Location - thoracic region Pain is radiating to the abdominal region. Aggrevating factor - sudden postural change Sometimes associated with dry cough. Patient also had dizziness at times . Associated diseases : Hypertension , Diabetes PAST HISTORY : Previously , the patient had 2 episodes of pain Patient had a stunt 1 month back PERSONAL HISTORY :  Diet - no proper apatite  Sleep - no proper sleep Bowl and bladder - normal Addictions - No FAMILY HISTORY :  Hypertension since 20 years Diabetes Mel
Read more

GM - 05

Image
March 06 2023 Case 05 Hi , I am V.Shivani 3rd year dental student .This is online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio. CASE SHEET: A 70 year old male patient came with a chief complaint of headache and slurred speech. CHIEF COMPLAINT:  Headache on left side from 15 days Difficulty to speak and slurred speech from 15 days Intermittent cough with sputum from 1 week HISTORY OF PRESENT ILLNESS: Headache - Insidious unilateral headache on left side from 15 days ,the pain is radiating downwards to neck , dragging type of pain. Slurred speech - He had difficulty in speaking from 15 days, decreased fluency and intensity of speech. Cough - It is associated with thin sputum , intermittent and no diurnal variation . He is not associated with fever,cold ,nausea. PAST ILLNESS: No hypertension No Diabetes No TB No Asthma FAMILY HISTORY: NIL PERSONAL HISTORY: Diet - Mixed Appetite - Normal Sleep - N
Read more

GM - 03

Image
February 27 2023 Case 3 February 27 2023 Hi, I am V.Shivani 3 rd sem dental student . This is online elog book to discuss our patient health data after taking her consent . This also reflects my patient centered online learning portfolio . CASE SHEET : A 70 year old female came with a complaint of fever and cold . CHIEF COMPLAINT : Intermittent fever since 15 days Cold from 3 days associated with dry cough Cough is present since 2 days and it is occasionally seen. HISTORY OF PRESENT ILLNESS : The patient was apparently asymptomatic 15 days before,then developed fever 15 days back also had cold from 3 days associated with dry cough that is no sputum . Fever is intermittent it is reduced when medication is used . Patient also had body pains , non radiating chest pain. She also had knee pains . Blood test reports had shown decreased levels of haemoglobin. Patient has dry mouth and feels thirsty frequently. PAST ILLNESS: Hypertension - present since 30 years Diabetes mellitus - present fro
Read more