GENERAL MEDICINE ELOG

 Hi, I'm A Satyanarayana, 3rd semester(Roll 12) 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 yrs old male patient daily wage worker by occupation came to OPD with abdominal distention 1 day back bilateral lower limb swelling since 10 days back and fever on and off since 10 days. 

CHIEF COMPLAINTS: 

 The patient came to OPD with abdominal distention 1 day back and  bilateral lower limb swelling since 10 days back and fever on and off since  10 days

 History of present illness: 

The patient was apparently alright 5 yrs back there he developed b/l pedal edema and developed shortness of breathe during excretion then went to private hospital and diagnosed with DM and CRF on conservative management 

HISTORY OF PAST ILLNESS:

Pedal edema and shortness of breathe on rest 

DM 5 yrs ago and CRF 5 yrs ago on conservative management 

TREATMENT HISTORY: 

No asthma 

Diabetic

No TB 

No surgeries done 

No CAD 

FAMILY HISTORY: 

No family History 

PERSONAL HISTORY:

OCCASSIONAL INTAKE OF ALCOHOL

MICTURITION IS  ABNORMAL 

 GENERAL EXAMINATION:

Vital signs: 

Temperature: 98.6F  

Pulse rate: 112/min 

Respiratory rate 18 /min 

No icterus 

No pallor 

No clubbing of fingers 

Putting oedema is present 

Patient is conscious 

PROVISIONAL DIAGNOSIS: 

CKD ON MHD 

INVESTIGATIONS DONE: 

LFT 

SERUM electrolyte 

SERUM iron 

Hemogram 

Esr

Complete blood picture

Random blood sugar

Blood urea 

ECG

SERUM creatinine 

SERUM chloride

Urinary potassium 

Ultrasound form

TREATMENT GIVEN:

 WHERE IS THE ANATOMICAL LOCATION OF PATIENTS PROBLEM?? 

It is a clinical syndrome characterized by chills and fever , flank pain,and constitutional symptoms caused by bacterial invasion of the kidney . Macro anatomical location is RENAL PELVIS in kidney

Why is the patient having this problem? (related to microanatomical pathogenesis as well as macro-social environmental events influencing

WHAT ARE WE DOING ABOUT IT?? (pharmacological and non pharmacological interventions)