General medicine case history 8

April 29, 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed 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.

A 24 year old male patient, resident of Devarakonda, Cowherd by occupation came to our hospital with chief complaints of-

1. Reduced urine output with involuntary in action

2. Shortness of breath which is insidious in onset, gradually progressive

3. Pedal edema.

Date of admission :- 09/03/2022

History of present illness:-

Patient was apparently asymptomatic 10 days back and developed fever which is insidious and intermittent, and reduced urine output with involuntary in action.

History of past illness:-

Not a known case of diabetes, hypertension, tb, epilepsy

10 years ago he had same problem.

Personal history:-

Patient has normal eating habit with mixed diet.

No alchohol consumption and no smoking.

Daily routine:-

Patient used to wake up at 7.00AM , takes breakfast at 9.00AM .Then he goes to his work and takes rice in between 4.00PM-5.00PM and dinner at 8.00PM and goes to bed by 9.00PM.

Family history:-

No significant family history.

General examination:-

Patient is conscious, coherent, cooperative and well oriented to time, place and person.

Pallor present

No icterus

No clubbing

No lymphadenopathy

Pedal edema present

Vitals:-

Temperature-99 F

Pulse rate- 88 bpm