General medicine Case 3

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 73 years old male, carpenter by occupation presented to hospital with following complaints :

Symptoms of Nausea, loss of appetite. From 1 month was initiated with dialysis  from then he was on Maintenance haemodialysis -( 2 times /week)

Now he came for readmission.

HISTORY  OF PRESENT  ILLNESS :- 

No decreased urine output. 

No pedal edema. 

No shortness of breath. 

PAST HISTORY :-

11 years Patient consulted a doctor due to swelling in lower libms 

The patient was on CKD (conservative treatment for 10 years) 

The patient doesn't suffer from Diabetes mellitus.

The patient doesn't suffer from from hypertension.

The patient does not suffer from asthma.

The patient does not suffer from tuberculosis.

The patient does not suffer from epilepsy.

The patient does not suffer from CAD.

The patient have not undergone any surgeries.

PERSONAL HISTORY : -

The patient has normal appetite. 

The patient is adequately nourished and is well bulit. 

The patient has normal micturition. 

No known of any allergies. 

Patient has given up the habit of alcohol consumption 10 years back. 

FAMILY HISTORY :

No one in her family complains of a similar history.

No one in their family suffers from any genetic conditions or deformities.

ALLERGY HISTORY:

 Patient is not allergic to any known drug or food.

There is no known allergy to dust or pollen in the patient.

GENERAL EXAMINATION:

The patient is concious, coherent and cooperative.

On examination, patient's mood appears   to be well and is well built.

 There is no lymphadenopathy present.

 There is no presence of clubbing.

 There is no  pallor. 

 There is no icterus.

 There is no cyanosis.

 There is no oedema of feet.

 Patient is not dehydrated.

VITALS :

 Temperature - 98.4 f

 Pulse - 84 beats /min.

 Respiration rate - 24 /min

 BP - 130/70 mm/hg.

PROVISIONAL DIAGNOSIS :

 - Chronic kidney disease on Maintenance haemodialysis.