General medicine E-log(1)





July 06, 2022


Hi, I'm G. Manish Reddy (roll:46), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.


CASE SHEET:

Chief complaint:

A 46yr old patient who is farmer by profession came to OPD with the chief complaint of decreased urine output and shortness of breath since 20days


History of present illness :

Patient was apparently asymptomatic 15yrs ago. Then he developed high grade fever for which he consulted local doctor and was diagnosed with type2 Diabetes Mellitus. He was assigned a diabetic diet. 3yrs ago he was gaining weight for which he visited doctor and was diagnosed with hypothyroidism and renal disease. He was started on dialysis on October 2021. He came to our hospital for dialysis and has been on it for past 8months (twice a week)



History of past illness :

Diabetes milletus since 20 years

Hypertension since 15 years

No TB

No epilepsy

No CAD 


Past history:

Patient was diagnosed with malaria 15 years ago

Diagnosed with hypothyroidism 3 years ago



Personal history:

Diet: mixed

Appetite: normal

Bladder/ Bowel movements: decreased urine output

Sleep: adequate

Addictions: alocoholic but stopped drinking 15yrs ago


Allergic history;

No known allergies


Drug history;

No drug history



Family history;

No known cases in family




PHYSICAL EXAMINATION;

General Examination:

Patient is conscious, coherent, comfortable 

Obese built

Pallor is present

No icterus

No cyanosis

No general lymphadenopathy

No clubbing of fingers

Unilateral oedema of hands and legs



Vital signs;

Temperature: 97.8°F

Pulse: 88bpm

BP: 130/90

Respiratory rate: 16cpm

SpO2: 96%


Systemic Examination;

Cardiovascular system:

Cardiac sounds: S1 and S2

No thrills

No cardiac murmurs

Respiratory system:

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds

Abdomen:

Abdomen is obese

No tenderness

No palpable mass

Non palpable liver and spleen

INVESTIGATIONS DONE;

RFT

ECG

CBP

HBSAg



Provisional diagnosis;

Chronic Kidney failure 







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