A 52 yrs Old male patient farmer by occupation resident of suryapet came to old with complaint of vomiting on and off from 4 months reduced appetite bilateral pedal oedema since 4 months burning micturation from 4 months Pt was apparently asymptomatic 4 months back then developed vomiting 6-8 epi



 Hi, I am Niteesh Gangina (roll no :81)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.




Chief complaints 

A 52 yrs Old male  patient farmer by occupation resident of suryapet came to old with complaint of vomiting on and off from 4 months reduced appetite bilateral pedal oedema since 4 months burning micturation from 4 months 

Pt was apparently asymptomatic 4 months back then developed vomiting 6-8 episodes a day 

History of present illness

Bilateral pedal odema pitting type gradually progressive 

Decreased appetite 

No history of hematuria fever and dyspnonea

History of past illness

Know case of diabetes mellitus hypertension ckd 

Medications not know

Personal history 

Occupation daily labourer 

Diet:mixed

Bowels irregular

Appetite decreased 

Micturation irregular

Sleep:normal

No known allergies 

Habits:alcohol taken regularly 


FAMILY HISTORY 

 Diabetes - yes

Hypertension -yes

Heart disease - No

Stroke - No 

Concern - No

Tuberculosis-no

Asthma - No

General examination 

No pallor 

No icterus 

No cyanosis 

No clubbing of fingers

No lymphadenopathy 

pedal odema 











SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - No

2. Wheeze - No 

3. Position of Trachea - Central

4. Breath Sounds - Vesicular

5. Adventilious Sounds - No

D. ABDOMEN

1. Shape of abdomen - Scaphoid 

2. Tenderness - No

3. Palpable mass - No 

4. Hernial Orifices Normal 

5. Free Fluid No 

6. Bruits No 

7. Liver - Not palpable

8. Spleen - Not palpable 

9. Bowel sounds -Yes

Reflexes  normal

Cerebellare signs

Finger nose coordination no

Knee heel coordination no


Investigation 














Provisional diagnosis:chronic kidney disease with known case of diabetes mellitus and bypertension


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