40 year old male with chief complaint of decreased urine output since 8 days

Hi,I am G.Shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.


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

40 year old male patient who is an advocate came to general medicine opd with cheif complaints of decreased urine output since 8 days.

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 5years back then developed decreased urine output since 8 days and underwent dialysis at Hyderabad.He had Renal tubular acidosis and right hip joint fracture

HISTORY OF PAST ILLNESS 
Chronic kidney disease on maintenance heamodialysis since 11 years,hypertension since 5 years .
No history epilepsy,TB,asthma ,diabetes,CAD.
Surgical history-right hip joint surgery 10 days back.


FAMILY HISTORY - no relevant family history

PERSONAL HISTORY
Diet- mixed
Appetite - normal
Bowel movement - regular
Bladder movement - irregular
Sleep -adequate
No history of addictions

ALLERGIC HISTORY - No known allergies

DRUG HISTORY
He is on regular medication for HTN
Arkamine-0.1 mg
Nicardia-20 mg

PHYSICAL EXAMINATION

GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor 
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers 
Pedal edema - PRESENT (pitting type)

VITAL SIGNS-
Temperature: 98.6F
Pulse:82 bpm
BP: 170/100 mm of Hg
Respiratory rate: 14cpm
SpO2: 98 percent
GRBS-102 mg%

SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs

RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Free fluid absent
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
no kerming's sign
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on maintenance hemp dialysis associated with hypertension. 

LAB INVESTIGATIONS :

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