General Medicine E-log (1)

 Hi, I'm Danush Varkur (roll:29), 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 50r old patient who is farmer by profession came to OPD with the chief complaint of decreased urine output, swelling of legs for the past 8 months

History of present illness;

Patient was apparently asymptomatic 8months ago. Then he developed oedema of legs and hands and developed fever. He visited the local doctor for the problem and the local doctor sent him to our hospital for further evaluation. On checkup, he was diagnosed with a kidney infection 

History of past illness;

Patient 

Past History;

And was diagnosed with hypothyroidism 6months ago

Personal history;

Diet: mixed

Appetite: normal

Bladder/ Bowel movements: decreased urine output 

Sleep: adequate

Addictions: alocoholic but stopped drinking 1yrs ago

Allergic history;

No known allergies

Drug history;

No drug history

Family history;

No relevant family history 

PHYSICAL EXAMINATION;

General Examination:

Patient is conscious, coherent, comfortable and co-operative

Obese built, moderately nourished

No pallor

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 

What are we doing; (Treatment)

The patient is undergoing dialysis two times a week for the past 8months along with some medication

The patient has reported that his urine output is back to normal but the edema is persistent 

MEDICATION;