General medicine e log

 Hi, I am A satyanarayana (roll no 12) of 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 66 yrs old male patient singareni employee by occupation with kidney problem has come to hospital for dialysis 

Chief Complaints:

The patient came to the hospital  with chief complaints of decreased urine output and shortness of breath 

HISTORY OF PRESENT ILLNESS:

Patient is a know case of kidney problem from 3 yrs  ago as he admitted in a private hospital in hyd due to symptoms of heart attack   ...

     There he was diagnosed with infection of liver ,fluid within the lungs, kidney infection and blockage of artery in brain 

There doctors said about kidney problem

HISTORY OF PAST ILLNESS:

The patient had gone with a Retinal surgery 

The patient is a known case of Diabetes and Hypertension since 25 yrs ago 

He met with corona 

The patient is not a known case of asthma and tuberculosis 

FAMILY HISTORY:

His wife is suffering with Diabetes  

His son got diabetes since 1 yr ago 

PERSONAL HISTORY:

Diet :normal 

Apetite: normal 

Micturition: abnormal 

Occassionally alcohol intake 3 yrs back 

Bowels : normal 

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:

Complete urine examination

Hemogram 

SERUM iron 

Random blood sugar 

LFT 

RFT 

Anti HCV antibodies 

HIV 1/2. Rapid test 

PROVISIONAL DIAGNOSIS: 

CHRONIC KIDNEY DISEASE ON MHD 

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 3rd time it was he is going on and 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 

Followed up: His present weight is 44 kg 

Now he is getting dialysis on 27 of jun