65 year old male patient presented with reduced urine output and generalised swelling.
E LOG GENERAL MEDICINE.
Hi, I am G Sai Karthik, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
- This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
CASE SHEET.
Chief complaints and duration.
A 65 year old male patient who was previously a farmer by profession came to the opd with the chief complaint of total absence of urine output and generalised swelling since ten days.
History of present illness.
Patient was apparently asymptomatic four years back and then suddenly developed pain in abdomen and tightness and came to the hospital for which he came to the hospital and diagnosed with renal caliculi. He underwent percutaneous nephrostomy and later discharged. He later developed generalised weakness and dizziness for which he was diagnosed with high blood pressure two years back and was on irregular medication. And two years ago on being unresponsive, he was in ICU for 4-5 days and diagnosed to be hypoglycaemic and creatinine level was 5.94. On recommending dialysis he refused it and got discharged. He has pedal oedema on and off. He had puffiness ad face days back for which he consulted a local doctor, who prescribed medication. Urine output has completely stopped from the next day. Went to Nalgonda and undergone 4 sessions of dialysis. He had come to our hospital on 4 July and has later undergone dialysis on 5 July. Urine output has not yet started.
History of past illness.
Renal calculi were found 4 years back; nephrostomy
Diabetic since 2 years.
Hypertension since 2 years.
No TB
No CAD
No Syphilis
No Asthma
Family history.
Mother had Diabetes Mellitus.
Allergies.
No allergies
Drug history.
No regular drug usage
Personal history.
Patient was previously a farmer by occupation.
Appetite is normal
Mixed diet
Bowel movement is regular.
Anuria since 10 days
Regular Smoking since past 6 years stopped 10 days back because he was having puffiness in face
Occasionally drinking
Sleep was adequate
PHYSICAL EXAMINATION.
A. General Examination
Conscious coherent and cooperative
Well built
Pallor is present.
Icterus is present
No cyanosis
No clubbing of fingers
No lymphadenopathy
oedema of feet and hands.
Puffiness of face
Vitals.
Temperature: 101 F
Pulse: 96
Respiration: 22/min
Blood pressure: 150/90 mmhg
Spo2: 96%
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
No dyspnea
No wheezing
Vesicular breath sounds .
D. Abdomen
Abdomen is Obese
No tenderness
No Palpable mass
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