A 42 year old male patient presented with Hypertension.
E LOG GENERAL MEDICINE.
Hi, I am Anvitha, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
CASE SHEET.
Chief complaints and duration.
A 42 year old male patient who was a mason by profession presented giddiness, palpitations on and off, difficulty in breathing and headache since morning on 28/11/22.
History of present illness.
The patient was apparently asymptomatic and alright till morning when he developed palpitations and shortness of breath (grade 2) and he also had headache.
History of past illness.
H/O similar complains in past one year.K/C/O Hypertension since one year and was on medication but stoppedH/O AKI and CKD.Personal history.
Appetite normal
Bowel movements regular
Burning Micturition
Sleep inadequate last night
Addictions : Regular Alcohol consumption.
Family history.
No significant family history.
PHYSICAL EXAMINATION.
A. General Examination
Pallor is present.
Icterus is absent
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet and hands.
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
dyspnea absent
No wheezing
No Vesicular breath sounds .
Position of trachea - central
D. Abdomen
Abdomen is scaphoid
No tenderness
No Palpable mass
Bowel sounds anew present
No bruits
No free fluids
E. Central nervous system
The patient was conscious coherent and cooperative.
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