General Medicine

I'm Maimuna Fathima,3rd year BDS student 
February 28,2023

This is an E-log to discuss case scenario of a patient.
I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan.

A 60 year old female was resident of Nalgonda came to OPD on 26th feb 2023,with chief complaint of 
-Decreased urine output 
-Pain in lower Abdomen 

History of present illness:
Patient of apparently asymptomatic 5 years ago then she started feeling difficulty in passing out urine and started experiencing Shortness of breath.She also started feeling pain in the lower Abdomen from past 3 days.

Past history:
Hypertension since 4 years 
Diabetes since 7 years 

Family history:Not significant 

Personal history:
Diet:Vegetarian 
Appetite:Decreased 
Bowel and bladder:Not regular 
Sleep:Inadequate 
Addictions:None 

General examintion:
Patient was conscious,coherent,cooperative and well oriented to time,place and person.
Pallor:Not seen
Edema:Not seen
Clubbing:Not seen.



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