E log august - 3
E-LOG GENERAL MEDICINE
Hi, This is Rithika, 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
A 55 YR OLD FEMALE WITH CRF
Chief complaints :
Itching since 3 mnths
Back aches, leg aches, pedal edema since 6 mnths even after medication
Past history :
HTN since 15 yrs - is on medication
Personal history:
Lack of sleep and appetite
Mixed diet
Bowel and bladder habits normal
Toddy drinker - 1 glass/day for 30 yrs
Family history : Nil significant
General examination :
Pallor - present
No icterus, cyanosis, clubbing, lymphadenopathy, oedema and malnutrition.
Vitals :
Temp : 99°F
PR : 82/min
RR : 18/min
BP : 160/100 mmHg
SPO2 : 98%
Systemic examination:
CVS:
S1, S2 heard
No thrills and murmurs heard
RS:
No dyspnoea, wheeze
Trachea - central in position
Breath sounds - vesicular
P/A :
Shape of abdomen - scaphoid
No tenderness and palpable mass
No free fluid and bruise
Liver and spleen not palpable
CNS:
Conscious and coherent
Speech - normal
No signs of meningeal irritation
Provisional diagnosis:
CRF ( 2° to HTN / NSAID abuse)
Investigations :
Treatment :
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