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:














Provisional diagnosis 
Chronic kidney failure 

Anatomical location of the problem

The problem of the patient is in the kidney in the pelvis region

What are we doing?(treatment)

The patient is undergoing dialysis as said 2 times a week from 3months along with some medication 

The patient has reported that his condition is getting better and his urine output got normal and is much better than before he started dialysis. 

Medication:






Comments

Post a Comment

Popular posts from this blog

A 60year old man came to hospital with complaints of tremors in right hand

Image
  Hi I am, AnirudhManne (roll no:11), 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. A 60year old male agricultural worker by occupation came to hospital with complaints of tremors in right hand Chief complaints Patient complaints of tremors in right forearm and hand History of presenting illness Patient was apparently asymptomatic 2years back He then developed shivering of right hand and arm which was     Insidious on onset and gradually progressive Initally shivering was localised to fingers only, later radiated to Palm.     numbness present Decreased power in right hand inability to hold things,unable to eat food, unable to work.     pain in right thigh     Shivering of right hand aggravated due to stress, anxiety fear, present for sometime during sleep.     Shivering is present throughant the day Intensity increases and dec
Read more

A 40year old male came to hospital with snake bite

Image
  Hi I am, AnirudhManne (roll no:11), 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. Chief Complaints: Bilateral loin pain since 3days. History Of Presenting Illness: Patient was apparently asymptomatic 7days back then he sustained snake bite (with Russell viper) on left ring finger while working in the fields,visited local hospital and managed symptomatically.  C/O bilateral loin pain,insidious in onset ,intermittent,gradually progressive,pricking type ,non radiating,aggravates on lying down. He has low grade fever,Nausea and vomiting. Not a known case of Burning Micturition,decreased or increased urine output.  No history of cough,cold,body aches,chest pain. Past History: N/k/c/o diabetes HTN,Epilepsy,Tuberculosis,CAD,CVA Personal History: Diet : Mixed  Appetite : Normal Sleep : Normal Bowel and bladder moments :Regular  Addi
Read more

A 65 year old came to casualty on 10/10/2023

Image
Hi I am, Anirudh Manne (roll no:11), 6th 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.   A 65yr old male came to casualty on 10/10/23 with history of fall Chief complaints Patient had suffered from fall on 10/10/23 and complains of pain in neck since fall History of presenting illness patient was apparently asymptomatic till yesterday  Patient was brought to casualty with History of fall (slips fall) over the floor on his left side of the face and has    pain in back of the neck unable to    move his right upper and lower limb(weakness) since the event on 10/0/23 at his home at 5:30pm near miryalaguda. pain in back of neck which is loacalised and non radiating severe in intensity Tenderness present on site of pain Past history  Not a known case of  diabetes mellitus Hypertension  Epilepsy Asthma Tuberculosis History of cataract op
Read more