GENERAL MEDICINE ELOG

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VIJAYA RATNA 34
Hi,I am Vijaya ratna 5th sem Medical student.This is an online elog book to discuss our patient's health data shared after taking his/her/guardian's consent.This also reflects patient centered care and online learning portfolio.This E-log book reflects patient- centered online learning portfolio.

A 50 year old female who is an agricultural labourer came with chief complaints of 
B/L pedal edema since 1 week
Abdominal distension since 1 week
Shortness of breath since 4 days

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 week back and developed pain in the chest which was non radiating type,not associated with sweating and palpitations.B/L pedal edema,pitting type upto knees.No aggrevating and relieving factors.She developed shortness of breath on exertion 4 days back.

PAST HISTORY
Known case of Hypertension since 1 month
N/K/C/o DM,TB,Asthma,Epilepsy

PERSONAL HISTORY
Appetite - normal
Mixed diet
Bowels - Regular
Micturition - increased frequency of urine 1 week back.But now it seems to be normal

TREATMENT HISTORY
She used few anti hypertensive drugs for  10 days and discontinued

GENERAL EXAMINATION

Patient was conscious, coherent, cooperative and examined in a well lit room

VITALS
Temperature -99 F
Pulse rate - 82/min
Respiratory rate - 24/min
Blood pressure - 180/90mmHg
SpO2 - 97%
GRBS - 112mg%

PHYSICAL EXAMINATION
Pallor - Absent
Icterus - Absent
Cyanosis - Absent
Clubbing of fingers/toes - Absent
Lymphadenopathy - Absent
Edema of feet - Absent
Malnutrition - Absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM
Thrills - No
Cardiac sounds - S1 and S2 present
Cardiac murmurs - No

RESPIRATORY SYSTEM
Dyspnoea - present
Wheeze - Absent
Position of trachea - central
Breath sounds - vesicular

PER ABDOMEN
Obese Shaped abdomen
No Tenderness
No Palpable mass
No Free fluid 
No Bruits
No Bowel sounds heard
liver and spleen - not palpable
CNS - NAD

INVESTIGATIONS
Ultrasound
2D ECHO
ECG
2/7/2022
BLOOD UREA
SERUM ELECTROLYTES 
T3,T4,TSH

PROVISIONAL DIAGNOSIS
Hypertension Urgency

TREATMENT
BP monitoring every 4th hourly
Tab Pan 40mg OD
Tab Naproxen 250mg BD
Tab Lasix 20mg BD
Tab Levocitrizine 5mg OD








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