GENERAL MEDICINE E-LOG

Chinthakuntla.Sowmya  Rani
Roll no:154
3rd semester 

A 60 years old male patient ,who is not working since 10 years came to casuality with the Chief complaints of
1.Shortness of breath -grade 4
2. Pedal edema - 2 months

History of presenting illness
Patient was apparently asymptomatic , 
2 years back then he had c/o small ulcer over left leg & went to hospital & on regular medications for ulcer 
Diagnosed CRF & on regular medications 

2 months back Patient c/o pedal edema went to local hospital Diagnosed with grade- 2 ,3 pitting 
Bilateral CRF since then he is having SOB  from 15 days 
Orthopnea present 
No PND 
No Chest pain
No palpitations 

C/O decreased urine output 
No c/o of burning micturition 
Discontinued medications last 15 days

History of past illness 
No h/o HTN,DM,epilepsy ,TB, Asthma

PERSONAL HISTORY 
Apetite - lost
Diet- mixed
Sleep- Adequate 
Bowel- Regular 
Micturition- Abnormal 
Addictions- Alcohol drinking daily 90-180ml /day since 40 years
Smoking - 18-20 beedis / day
No h/o drug use
 
Family history 
Not significant 

General examination 
O/E pt is conscious, coherent, lean 
Pallor- present 
Icterus-no
Cyanosis- no 
Clubbing-no
Lymphadenopathy- no
Malnutrition- no
Oedema- pedal

Vitals
Temp-98.6 F
Bp-130/ 80mmHg
Pr- 105
Rr-20 rpm
SpO2-99 °/°
 
Inspection :
Shape of chest- normal
Symmetry of Chest- symmetrical
No deformities of spine 
⁃ No visible apical impulse 
Palpation:
        -No tenderness and no local rise of temperature 
⁃ Inspectory findings are confirmed
⁃ Trachea central 
⁃ Apex beat : felt at 5 th Intercoastal space medial to mid clavicular line

CVS- S1,S2 heard,no murmurs

Respiratory-:
Dysnea- present 
Wheeze - present 
Position of trachea- central 
Breath sounds  - vesicular 
Adventitious sounds- crepts

Abdomen:
Shape - Scaphoid 
No tenderness, palpable mass, Fluid , bruits
Bowel sounds- present 
Central nervous  system:
Level of consciousnes- conscious 
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit 

Provisional diagnosis:
CRF-Uremic encephalopathy 

Investigations:













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