General Medicine Blog _1
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.
Name : J.Rajarajeshwari
Roll no : 51
2020 Batch
I''ve been given this case to solve in an attempt to understand the topic of "PATIENT CLINICAL DATA ANALYSIS" to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and comeup with Diagnosis and Treatment plan.
A 40 year old male came to opd who is advocate by occupation came with
CHIEF COMPLAINT:
He came with decreased urinary output since one week
HOPI:
Patient was a known case of Hypertension from past 5 years . He was apparently asymptomatic 5 years back .He developed decreased urinary output since one week .He under went dialysis at out side hospital . He met with a road traffic accident and had injury at the right hip joint . Again he fell down while walking with the help of attender and had injury at the left knee joint .
PAST HISTORY:
He is a known case of Hypertension from past 5 years and he was under going dailysis from past 5 years.
No diabetes mellitus
No tuberculosis
No asthma
No epilepsy
He under gone right hip joint surgery 10 days back
PERSONAL HISTORY:
Single
Advocate by occupation
Normal appetite
Diet :mixed
Regular bowels
Normal micturition
No allergies
No addictions
FAMILY HISTORY:
His father , mother , and his three sisters are known cases of Hypertension .
GENERAL EXAMINATION:
Conscious, coherent, co-operative, moderately built and moderately nourished
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing of fingers/toe : absent
Lymphadenopathy: absent
Pedal edema : absent
VITALS:
Temperature: 98.2 F
Pulse rate : 82 bpm
Respiratory rate: 14 breaths per min
BP: 170/100 mm/hg
SPO2:98 % at room air
GRBS:102mg %
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
CKD on MHD
Known case of Hypertension
