55 year old male with chief complaint of generalised weakness since 3 days and loss of appetite

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome 

55 year old male patient resident of nalgonda ironing clothes by occupation presented to opd with the chief complaint of generalised weakness and loss of appetite

HISTORY OF PRESENT ILLNESS
Loss of appetite :- since 25 days 
He complains of feeling of vomiting sensation on tasting any food 
He tastes bitter on eating any food in whole day 

Generalised weakness :- since 3days 
Patient complains of backache while trying to get up from bed
He complains of cough with sputum since 5days

PAST HISTORY
Bp since 2 years (maintaining on amlodipine)
Dialysis sessions for 6months 2 years back
Since 1 year he is on conservative management

PERSONAL HISTORY 
Not an alcoholic 
No drug alergies 

FAMILY HISTORY
no significant family history 

GENERAL EXAMINATION 
 pallor is present 
No icterus
No clubbing 
No cyanosis 

Vitals 
Temp 98.4
Bp 150/90
Pulse:- 86
Respiration:- 19 times, normal 

SYSTEMIC EXAMINATION 
CVS s1 and s2 are heard 
CNS speech is normal , reflexes are normal 

Per abdomen :- 
No fluid present 
No palpable mass

Respiratory system :-
Bilateral wheeze sounds are heard 
Infra and supra mammary 
Infra  and supra clavicular 
Axillary areas 

INVESTIGATIONS 
LFT
RFT
HEMOGRAM
ULTRASOUND
ABG
2D ECHO
ECG
CLINICAL IMAGES OF PATIENT






Comments

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