General medicine E-log - Prasannakalyan - 52

  This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.   Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.   This E-log also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan. CASE SCENARIO: A 50 year old male presented to the OPD with nausea, Facial puffiness, reduced urine output and Pedal edema  COMPLAINTS AND DURATION Weight loss   Pedal edema Decreased urine output Shortness of breath on exertion Facial edema Decreased appetite   HISTORY OF PRE

   This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent. CASE SCENARIO: This is a case of an 85 year old male presented to OP with Shortness of breath, Vomiting since 2 days and dysphasia. COMPLAINTS AND DURATION Shortness of breath  Vomiting since 2 days dysphagia  HISTORY OF PRESENT ILLNESS Diagnosed with Heart disease 2 years ago. Shortness of breath as of one week ago followed by Dysphagia and vomiting as of 2 days. HISTORY OF PAST ILLNESS Not a K/C/O HTN, DM, asthma, epilepsy Unhealed ulcerated foot for the past 10 years. Surgery done to graft thigh muscle to the foot but has shown no improvement TREATMENT HISTORY Thigh muscle graft to feet for non healing ulcer Has been regularly tested for DM and HTN. PERSONAL HISTORY Appetite - lost Bowels- regular Micturition -normal No known allergies Quit alcohol and Cigarettes 8 years ago on recommendation by physician for non healing ulcer FAMILY HIS