A 65 year old male came to OPD who is formerly a farmer with Shortness of breath - 10 months Pedal edema - 10 months Decreased urine output - 2 months

General medicine elog 

Hi , I am G.M Sai Bhuvanesh,3rd semester 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.

The patient’s consent was taken verbally prior to history taking and examination of his/her condition.

A 65 year old male came to OPD who is formerly a farmer with 

CHIEF COMPLAINTS

Shortness of breath - 10 months

Pedal edema - 10 months

Decreased urine output - 2 months

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 years back then he developed severe back ache and he went to a hospital in khammam and he was diagnosed with chronic kidney disease and he is on maintainance hemodialysis from 10 months.he visits hospital every alternative day for hemodialysis

PAST ILLNESS

No similar complaints in the past

K/C/O Hypertension - 3 years 

N/K/C/O Diabetic Mellitus/Tuberculosis/ Epilepsy/ Asthma/COPD

FAMILY HISTORY

Not relevant

PERSONAL HISTORY

Mixed Diet 

Appetite- lost

Sleep - adequate

Bowel and bladder movements-normal 

Addictions - occasional toddy drinker 

GENERAL EXAMINATION

Patient is conscious,coherent and cooperative

moderately built and well nourished

No pallor  

No icterus 

No clubbing of fingers

No cyanosis 

No Lymphadenopathy

No pedal edema - presently

SYSTEMIC EXAMINATION

CVS 

S1 and S2 sounds heard 

No murmurs

No thrills 

RESPIRATORY SYSTEM

No dyspnea

No wheeze

Central location of trachea

Vesicular breath sounds 

ABDOMEN 

Abdomen is scaphoid

No tenderness

No palpable mass 

Normal hernial orifices 

Non palpable liver and spleen

Bowel sounds are heard 

CNS 

Conscious 

Speech- normal

Signs of meningeal irritation - 

no neck stiffness

no kerming's sign

Cranial system - intact 

Motor system - intact 

Sensory system - intact 

INVESTIGATIONS


Provisional diagnosis - chronic kidney disease















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