general medicine blog5

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name  : G Maheshwari 
Roll no : 44

Chief complaints

A 60 year old male patient presented with

Loin pain since 1 month
Pruritus since 1 month
Shortness of breath since 1 month
Fever since 5 days

History of present illness

Patient was apparently asymptomatic 2 years back.
He came to casuality with loin pain since 1 month associated with generalized pruritus 5 days back which reduced on taking medication.
Now c/o shortness of breath from 5 days.aggravated on excertion.

Past history :
K/c/o diabetes mellitus since 2 years .
K/c/o HTN since 2 months .
No history of burning micturition,
No history of asthma ,TB,CAD, Epilepsy.

Personal history :
Married
Normal appetite 
Adequate sleep 
Mixed diet
Normal bowel habits
Normal bladder movements 
No addictions

Family history 
Not significant

General examination 

The patient is conscious, coherent, cooperative and well oriented 
No pallor
No icterus 
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No edema
Vital signs

Temperature-95.9 F
Pulse rate- 69 beats/min
Respiration rate- 16 cycles/min
Blood Pressure- 130/70 mm Hg
SPO2- 100%

Systemic examination

CVS
No thrills
Cardiac sounds S1,S2 heard
No cardiac murmurs

Respiratory system
No dyspnoea
No wheezing
Position of trachea- Central
Breath sounds- Vesicular

Abdomen
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Normal hernial orrifices
No free fluid
Liver- Not palpable
Spleen- Not palpable
No bowel sounds

CNS
Conscious
Speech- Normal
Cranial nerves, motor system, sensory system are intact
Vital signs

Temperature-95.9 F
Pulse rate- 69 beats/min
Respiration rate- 16 cycles/min
Blood Pressure- 130/70 mm Hg
SPO2- 100%

Systemic examination

CVS
No thrills
Cardiac sounds S1,S2 heard
No cardiac murmurs

Respiratory system
No dyspnoea
No wheezing
Position of trachea- Central
Breath sounds- Vesicular

Abdomen
Shape of abdomen- scaphoid
No tenderness
No palpable mass
Normal hernial orrifices
No free fluid
Liver- Not palpable
Spleen- Not palpable
No bowel sounds

CNS
Conscious
Speech- Normal
Cranial nerves, motor system, sensory system are intact
Investigation
Chronic renal failure

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