The patient of 65 years old came to the hospital 3days back with decrease urine output and decrease appetite with bilateral pedal odema



 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 


The patient of 65 years old came to the hospital 3days back with decrease urine output and decrease appetite with bilateral pedal odema


History of present illness

Apparently asymptomatic 3 years ago then presented with decreased urine output and appetite loose stool with 3-4 episodes per day watery in consistency.1year ago developed Shortness of breath .Fever since 3 days.


History of past illness

Had undergone laparotomy of appendicitis 30 years back
know case of Chronic kidney disease since 2 years.know case of hypertension since 2 years 
On medication:T.Prazesin 10mg,T.Arkamine0.1mg,T.Clinidipine10mg


4. TREATMENT HISTORY

  • Diabetes - No
  • Hypertention - Yes
  • CAD - No
  • Asthama - No 
  • Tuberculosis - No 
  • Antibiotics - No 
  • Hormones - No
  • Chemo / Radiation - No 
  • Blood Transfusion - No / Yes, 
  • Surgeries - Yes, Details:Abdominal Surgery Lapotomy
  • Other - No


Personal history 

Occupation daily wage worker

Married

Diet:mixed

Appetite:normal

Sleep:normal

No known allergies

FAMILY HISTORY 

 Diabetes - No

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 is seen





SYSTEMATIC EXAMINATION:

B. CARDIO VASCULAR SYSTEM

1. Thrills No 

2. Cardiac Sounds

3. Cardiac murmurs No 

C. RESPIRATORY SYSTEM

1. Dyspnoea - yes

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


Central nervous system 

1.level of conscious conscious and covert

2.speech normal

3.sign of menningeal irritation

Neck stiffness no

Kerning sign no

Cerebral signs

Finger nose test in coordination 

Knee heel test in coordination 

Investigation 

Provisional diagnosis:Chronic kidney disease

Treatment:Dialysis



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