General medicine elog 2
Hi, I am anirudh manne 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 50 yr old patient housewife by occupation resident of narketpally came to the hospital due to reduced urine output and shortness of breath
History of present illness
The patient was asymptomatic 6months ago later she was put on dialysis for the past 5 months
1month ago she started to complain about decreased urinary output(oliguria) and shortness of breath(grade 3)
The patient complained about facial puffiness which was reducing in size as the days progressed so was put under further dialysis
History of past illness
Patient is a known case of hypertension since 7months
Not a known case of diabetes melitus ,asthma,tuberculosis
Family history
No significant family history
Personal history
Diet:mixed
Appetite:normal
No allergies
No addictions in the past
Regular bowel movement
General examination
No pallor
No icterus
No lymphadenopathy
No clubbing of fingers
No poedal oedema
No cyanosis
Moderately built
Moderately nourished
Vital signs
Bp:150/80
Pulse rate:86/min
Respiration rate:21cpm
Spo2:98%
Systemic examination
Cardiovascular system
s1,s2 heart sounds heard
No additional sounds heard
Respiratory system
Trachea central in position
Normal breathe sounds heard
Gastrointestinal system
No tenderness over any region
No palpable mass in abdomen region
Central nervous sysytem
Patient is conscious
Speech:normal
All reflexes are present
E.c.g
Provisional diagnosis
Chronic kidney disease on Maintenence haemodialysis
Where is the anatomical position of the patients problem?
It is a disease where the patient suffers from decrease in the urinary output and facial puffiness
The anatomical position of patient's problem is in the kidney located in the renal pelvis
Why is the patient having this problem?
Chronic kidney disease is usually caused by other conditions that put a strain on the kidneys. Often it's the result of a combination of different problems.
As the patient is known case of hypertension over time, this can put strain on the small blood vessels in the kidneys and stop the kidneys working properly.
Even the area where the patient belongs has high amount of chlorine content in the water which may also be the cause of the patients kidney failure.
What are we doing?(treatment)
The patient was given blood transfusion due to low platelet count and anemia
Haemodialysis on a regular basis(2times a week) through internal jugular vein is being done for the last one month.
Tests done:
Haemogram
Serum iron
Dengue NS1 antigen
ecg
hiv rapid test
Renal function test
Random blood sugar
Drugs advised
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