GENERAL MEDICINE E-LOG

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

CHIEF COMPLAINT:

A 53 year old male came to the opd with chief complaints of 

• Shortness of breath since 1 week 
• Decreased urine output 
• Loss of appetite since 1 month 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 yrs back then he developed fever which is insidious in onset, not associated with chills n rigor, for which routine investigations were done which showed elevated serum creatinine levels.

He was a carpenter by occupation, due to his heavy workload, he developed body pains for which he took a lot of NSAIDs. 

Following the Investigations the patient was diagnosed with chronic kidney failure and is on medication since 10 years.

Routine Investigations were being done from the past 10 years. 

1 month back, there was increase in the creatinine level from the investigations.

He came to our hospital at present as he required Dialysis.

HISTORY OF PAST ILLNESS:

Not a k/c/o DM, Hypertension, Asthma, TB, Epilepsy

TREATMENT HISTORY:

The patient was on Nodosis for the past ten years for Chronic Kidney Failure.

PERSONAL HISTORY :

• Appetite is decreased

• Bowels - Regular

• Micturition - Normal

• No known allergies

• Patient was an alcoholic and a smoker 10 years back, then stopped drinking and smoking after he was diagnosed with Chronic Kidney Failure.

GENERAL EXAMINATION:

Patient is conscious.

Pallor is present 

Mild Dehydration is present.

Absence of  Icterus, cyanosis, pedal edema, clubbing, lymphadenopathy.

VITALS:

1.Temperature:- 98.4 F

2.Pulse rate: 98 beats per min

3.Respiratory rate: 18 cycles per min

4.BP: 120/80 mm Hg

5.SpO2: 99% @ Room air 

6.GRBS: 114mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard, no murmurs

RESPIRATORY SYSTEM:

• Dyspnoea is present
• Normal vesicular breath sounds
• Position of trachea is central

EXAMINATION OF ABDOMEN:

• Shape - Scaphoid
• No Tenderness
• No palpable mass
• Normal hernial orifices
• No free fluid 
• No Bruits 
• Liver is not palpable
• Spleen is not palpable
• Bowel sounds heard.

CENTRAL NERVOUS SYSTEM:

• Patient is conscious and coherent 
• No focal neurological defect 

PROVISIONAL DIAGNOSIS:

CKD ( Secondary to Analgesic Nephropathy) on MHD

INVESTIGATIONS:

Biochemical Investigations:

                          

Serum Creatinine 

Blood Urea

Serum Electrolytes

Pathological Investigation:

                               

CUE 

Ultrasound Report