A 40 year old male patient came to general medicine OPD with chief complaints of decreased urine output.
29 December 2022,
Hi, I am G.Anisha Reddy of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of her condition.
40 year old male patient who is an advocate came to general medicine with cheif complaints of decreased urine output since 8 days.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 5years back then developed decreased urine output since 8 days and underwent dialysis at out hospital Sai sanjeevini .He had Renal tubular acidosis and right hip joint fracture.
HISTORY OF PAST ILLNESS
Chronic kidney disease on maintenance heamodialysis since 11 years,hypertension since 5 years .
No history epilepsy,TB,asthma ,diabetes,CAD.
Surgical history-right hip joint surgery 10 days back.
FAMILY HISTORY - no relevant family history
PERSONAL HISTORY
Diet- mixed
Appetite - normal
Bowel movement - regular
Bladder movement - irregular
Sleep -adequate
No history of addictions
ALLERGIC HISTORY - No known allergies
DRUG HISTORY
He is on regular medication for HTN
Arkamine-0.1 mg
Nicardia-20 mg
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
Pedal edema - PRESENT (pitting type)
VITAL SIGNS-
Temperature: 98.6F
Pulse:82 bpm
BP: 170/100 mm of Hg
Respiratory rate: 14cpm
SpO2: 98 percent
GRBS-102 mg%
SYSTEMIC EXAMINATION
CVS:
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 scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Free fluid absent
Bowel sounds are not heard
CENTRAL NERVOUS SYSTEM
Conscious
Speech- normal
Signs of meningeal irritation -
no neck stiffness
no kerming's sign
Cranial system - intact
Motor system - intact
Sensory system - intact
Cerebeilar signs
Finger nose- in coordination
Knee heel - in coordination
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on maintenance hemodialysis associated with hypertension.
LAB INVESTIGATIONS :
Comments
Post a Comment