GENERAL MEDICINE

Hi, Iam Supriya 5th sem medical student. This is an online elog book to discuss our patients health data shared after taking his/her/guardians consent. This also reflects patient centered care and online learning portfolio. This E-log book reflects my patient -centered online learning portfolio. 

A 68year old female resident of chityala came to the casuality with chief complaints of 

-Dysuria
-Burning of Micturition

HISTORY OF PRESENT ILLNESS
 
      Patient was apparently asymptomatic before     2011.In 2011,she visited hospital with chief complaint of dysuria. Upon biochemical investigations, her serum creatinine level was high i.e., 2.0.
  In 2012 to 2018,she has diagnosed with occasional recurrent UTI/pyuria due to the presence of pus in urine on investigations. 
 On 21/5/22, she went to the hospital with chief complaint of leg swelling, decreased appetite, nausea and vomiting. She has diagnosed with CKD V, UTI, UROSEPSIS WITH ANEMIA. She underwent 4hemodialysis and AV FISTULA 15 days back and 2hemodialysis in kamineni. 

HISTORY OF PAST ILLNESS

Not a known case of DM/HTN/THYROID, CAD, CVD, TB, EPILEPSY. 
known case of osteoarthritis. 
Known case of CKD on medical management

PERSONAL HISTORY
Married
Mixed diet
Appetite -decreased
Micturition-dysuria
Bowel habits -regular
No addictions 

FAMILY HISTORY

No significant family history

MENSTRUAL HISTORY

Age of menarche-14 years

OBSTETRIC HISTORY

Age of marriage-21 years
Age of first child birth-22years
Gravida -4
Still birth-1

PHYSICAL EXAMINATION
A. General examination-patient was conscious. Responding When calls with different sounds. 
 
Pallor-present
Icterus -absent
Cyanosis-absent
Lymphadenopathy-absent
Oedema-present Grade 2 pedal edema
Malnutrition -absent
Dehydration-absent

VITALS

Temperature-
Pulse rate-126/min
Respiration rate-22/min
BP-180/90mmhg
Spo2 at room air -98%

B. Systemic examination
CARDIOVASCULAR SYSTEM
Thrills -No
Cardiac sounds -s1, s2 present
Cardiac murmers-absent

RESPIRATORY SYSTEM
Dyspnoea -No
Wheeze-no
Position of trachea-central
Breathe sounds -vesicular
Adventitious sounds-No

ABDOMEN
No tenderness
No palpable mass
Normal hernial orifices
Free fluid -No
Bruits-No
Liver-non palpable
Spleen-non palpable
Presence of bowel sounds

CENTRAL NERVOUS SYSTEM
consciousness
Speech-normal
Signs of Meningeal irritation-absent
Cranial nerves, motor and sensory system- intact
Glasgow scale-15/15

REFLEXES
Present
Plantor flexion bilaterally

CEREBRAL SIGNS
Absent

GAIT-Normal

INVESTIGATIONS
ECG
Hemogram
Haemoglobin-8.9gm/dl
TLC-6450
N/L/E/M/B-70/10/1/4/0

ABG
PH-7.50
PCo2-31.7
P02-141
Hco3-24.6

RFT
Urea-84
Creatinine-4.1
Uric acid-4.3
Calcium-9.5
P04--
Na+-142
K+-3.6
Chloride-102

PROVISIONAL DIAGNOSIS
CKD on MHD











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