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 













 Provisional Diagnosis: Chronic renal failure

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