E-log
Hi, I am anirudh manne(roll no :11)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
A 65 yr old male patient farmer by occupation with kidney problem from 2yrs has come to the hospital for dialysis.
Chief complaints
The patient came to the hospital 16days back with chief complaints of decreased urine output and shortness of breath
History of present illness
The patient is a known case of kidney problem from 2yrs when he was taken to another hospital he has been using medication for the last 2yrs as prescribed then he has been put on dialysis from 3months (2 times in a week).
History of past illness
The patient has partial deafness since 15yrs
The patient is also diagnosed with hypertension 2yrs back when he got to know about his kidney problem.
The patient is not a known case of diabetes,asthma
,tuberculosis.
Personal history
Diet:mixed
Appetite:normal
Sleep:normal
No known allergies
Family history
His brother is a known case of diabetes
His father is a known case of hypertension
General examination
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Poedal odema present at the time of admission
Now there is no poedal odema
Systemic examination
Cardiovascular system
S1 and s2 sounds heard
No murmurs
No thrills
Respiratory system
Trachea central in position
Breath sounds vesicular
No wheezing sounds heard
Central nervous sysytem
The patient is conscious
Speech: normal
Reflexes :present
Tests done:
RFT
E.c.g
Haemogram
Serum iron
Ultrasound
Random blood sugar
Results:
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