General medicine

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.

70 yr old male patient came to opd with c/o of chest pain intermittent since 15 days.
HISTORY OF PRESENT ILLNESS
 patient was apparently asymptomatic 3 months back,then he developed exertional dyspnea(grade II) associated with cough ,wet type of sputum.
History of pedal edema 3 months back which is pitting type.
HISTORY OF PAST ILLNESS
HTN since 4 yrs on tab telmisartan-40 mg
No H/O dm
No H/O TB
No H/O cad
No H/O epilepsy
PERSONAL HISTORY
Married
Appetite-normal
Diet -Non vegetarian
Bowel and bladder movements-regular
Allergies-no
PHYSICAL EXAMINATION
Pallor-present
Pulse rate-76/min
BP- 150/80
Respiration- 19/min

SYSTEMIC EXAMINATION
CVS-S1 S2 positive
Thrills- absent
Cardiac murmurs - absent

INVESTIGATION:
DIAGNOSIS:
Chronic renal failure
TREATMENT:
TAB-LASIX-40 mg BD
TAB-NICARDIA-10 mg BD
TAB-NICODOSIS-500mg BD
TAB-SHELCAL 500 mg OD
TAB-OROFER-OD


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