General Medicine

20-12-22

This is an online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

Date of Admission:

A 35 year old male patient, lorry driver by occupation, resident of Atthampet, came to the OPD with the 

C/O: Distension of abdomen since 6 days 
       : Bilateral lower limb swelling since 5 days 

HOPI:

-Patient was apparently asymptomatic 1 month ago and then devoloped abdominal distension and bilateral lower limbs edema since 6 days which were insidious in onset and gradually progressive, pitting type of pedal edema below knees of both lower limbs.

-Abdominal distension:

 


-Pitting type of Pedal Edema:

Past History:

-No history of similar complaints in the past.
-K/C/O Diabetes Mellitus, which was diagnosed 6 months ago.
-N/K/C/O HTN, epilepsy, CAD, CVA, TB, asthma.

Personal History:

-Diet: mixed
-Appetite: 
-Sleep:
-Bowel and Bladder movement: Since 5 days prior to admission to the hospital pt.had irregular bowel and bladder movements. Presently normal bowel and bladder movements 
-Addictions: Chronic alcoholic and smoker from 15years.

General Examination:

-Patient is conscious, coherent and co-operative.
Moderately built and nourished.

-Vitals: Temperature—> afebrile 

           :BP—>120/70 mmHg

           :PR—>74bpm

           :RR—>18cpm

-Pallor: present

-Icterus: present

-Cyanosis: absent

-Clubbing: absent

-Lymphodenopathy:absent

-Edema: pitting type of pedal edema seen below knees of both lower limbs.