General medicine E-log (2)

July 21, 2022

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 with decreased urine output with burning micturition and developed fever. He visited the local doctor for the problem and the local doctor sent him to the hospital for further evaluation. On checkup, he was diagnosed with a kidney infection. He has been on dialysis 2days per week for 4hrs for the past 8months. He also has cough for which he consulted the doctor. For which they tested and found to be normal but the cough still persisted.

Daily routine:

Patient usually wakes up at 4:30-5:00 am in the morning, goes to work in his field

The breakfast and lunch vary according to the work he has in hand. Sometimes he eats early and sometimes he may eat late. After being on dialysis, he stopped working completely

Past history;

Patient is a known case of diabetes for the past 6yrs

Patient has been suffering from kidney disease for the past 8yrs

Patient is a known case of Hypertension since 1yr

He's been taking medications for diabetes, hypertension

Personal history;

Diet: mixed

Appetite: normal after dialysis but feels full before dialysis

Bladder/ Bowel movements: decreased urine output, burning micturition

Sleep: adequate

Addictions: alocoholic since 25yrs but stopped drinking 1yrs ago. Non smoker

Allergic history;