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A 35 year old man with pedal edema and facial puffiness


E-LOG GENERAL MEDICINE
Hi, This is K.Srinija , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

★ CASE SCENARIO 

A 35 year old male patient who is Tractor driver by profession came to the OPD with chief complaints of :
- Abdominal pain since 3-4 days
- shortness of breath since 3 days
- vomitings (since 3 days)

★ HISTORY OF PRESENT ILLNESS :

- Patient was apparently asymptomatic  4 months back and developed bilateral pedal edema which is pitting type and associated with facial puffiness for which he went to the hospital and had creatinine levels 4.4mg/dl  and blood urea 44 mg/dl and also diagnosed with Hypertension 
- Three days back he developed  abdominal pain , dragging type which is gradual in onset and progressive in nature
- He shows H/O not passing stools since 3 days ( during time of admission ) 
- H/O vomitings since 3 days , fluids as contents 
- H/O shortness of breath ( Grade -3, since 3 days

★ HISTORY OF PAST ILLNESS
- K/C/O HTN since 4 months and on regular medication 
-N/K/C/O DM , TB , epilepsy , asthma 

★ TREATMENT HISTORY
- Taking treatment for HTN 

★ PERSONAL HISTORY 
- Married
- Mixed diet
- Bowel movements irregular
- Bladder movements normal
- No known allergies
- Takes alcohol daily - 90ml since 2 years 

★ FAMILY HISTORY 
- not significant

★ GENERAL EXAMINATION 
- No - pallor /icterus / cyanosis / lymphadenopathy / clubbing 
- BP - 180/120 mmg
- PR - 78 /min
-RR- 18 /min
- SPo2 -98% at RT
- Temp - Afebrile

★ SYSTEMIC EXAMINATION

— CVS 
- Thrills : No 
- Cardiac sounds - S1 , S2 heard 
- Cardiac murmurs : No 

— RS 
- Dyspnea : No 
- Wheeze : No 
- Position of Trachea : central 
- Breath sounds : vesicular

— ABDOMEN 
- Shape of abdomen : scaphoid
- tenderness prsent , no palpable mass 
- Hernial orrifices : Normal 
- No fluids , bruits 
- Liver and Spleen are not palpable
- Bowel sounds : no 

— CNS 

- patient is conscious 
- speech is normal 
- No signs of meningeal irritation 
- Higher motor functions intact 
— Reflexes 
- plantars - flexor

★ INVESTIGATIONS

                    3/8/22

               4/8/22

             5/8/22


          
   6/8/22


7/8/22
8/8/22


★PROVISIONAL DIAGNOSIS :    
           -CRF associated With HTN

★ Rx

3/8/22

- T.LASIX
- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.BUSCOPAN
- Inj.ZOFER
- Inj.TRAMADOL

4/8/22

* Pain Abdomen decreased by 10 % 
* 1 episode of vomiting
O/E
* Pt C/C/C
- BP : 200/120mmHg ( without medication )
- PR : 78/min
- CVS : S1,SE heard
- RS : Bilateral air entry present
- P/A : Tenderness present
-CNS : No focal abnormality detected 

- T.LASIX
- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.TRAMADOL
- Inj.ZOFER
-Inj.PAN
- Monitor vitals

5/8/22
*Pain Abdomen decreased by 50%
* C/O nausea
*No fever spikes
O/E
* Pt C/C/C
- BP : 180/100mmHg 
- PR : 82/min
- CVS : S1,SE heard
- RS : Bilateral air entry present
-CNS : No focal abnormality detected 

- T.LASIX
- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.TRAMADOL
- Inj.ZOFER
-Inj.PAN
- T.METROGYL
- BP monitoring 4th hrly
- IVF - NS
- Syrp ARISTOZYME

6/8/22

*No fever spikes
O/E
* Pt C/C/C
- BP : 130/80mmHg 
- PR : 82/min
- CVS : S1,SE heard
- RS : Bilateral air entry present
- P/A : Non Tender
-CNS : No focal abnormality detected 

- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.TRAMADOL
- Inj.ZOFER
-Inj.PAN
- T.METROGYL
- BP monitoring 4th hrly
- IVF -NS
- Syrp ARISTOZYME

7/8/22

* C/O pain Abdomen
O/E
* Pt C/C/C
- BP : 130/90mmHg 
- PR : 76/min
- CVS : S1,SE heard
- RS : Bilateral air entry present
- P/A :soft , diffuse , tenderness present
-CNS : No focal abnormality detected 
- NBM till further order
- IVF - DNS
- - T.LASIX
- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.TRAMADOL
- Inj.ZOFER
-Inj.PAN
- T.METROGYL
- BP monitoring 4th hrly
- Syrp ARISTOZYME

8/8/22

O/E
* Pt C/C/C
- BP : 140/90mmHg 
- PR : 78/min
- CVS : S1,SE heard
- RS : Bilateral air entry present
- P/A :soft , diffuse , tenderness present
-CNS : No focal abnormality detected 
- NBM till further order
- IVF - DNS
- - T.LASIX
- T.NICARDIA
-T.ARKAMIN
- T.NODOSIS
- T.OROFER
-Cap.BIO D3
- Inj.TRAMADOL
- Inj.ZOFER
-Inj.PAN
- T.METROGYL
- BP monitoring 4th hrly
- Syrp ARISTOZYME

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