General medicine case discussion

Hi, I am M Keerthan(Roll no:05) 3rd sem medical student. this is an online elog book to discuss our patients health data after taking their consent.This also reflects my patient centered online learning portfolio.

A 30yr old male came to the hospital with complaints of weakness 

Chief complaints:

The patient came to the hospital on tuesday with chief complaints of weakness and shortness of breath

History of presenting illness:

The patient was apparently asymptomatic 1yr ago then he visited a local hospital with complaints of weakness and pain at the lumbar region,then dialysis was recommended at the local hospital,for dialysis he visited Gandhi hospital,medications were given 6 months and told to stop alcohol and meat.he took medications for 1 month and and then stopped,he also started consuming alcohol.Then he visited Kims hospital 6 days ago with complaints of shortness of breath.

Negative history:

Fever- No history of fever.

Shortness of breath: history of shortness of breath 

Past history:

No significant past history 

Personal history:

Married

Occupation: labourer

Diet:mixed

Bowel movements:Normal

  addictions:alochol(regular)

Apetite: decreased 

Sleep:Normal

No known allergies

Hemogram

General examination:

Conscious

Coherent 

 UnCooperative 

No pallor

No icterus

No cyanosis

No clubbing of fingers

No lymphadenopathy 

Pedal edema:No

Complete urine examination