A 51YR OLD male

 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 patient's 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 the comment box.

25NOV 2021

A 51Y old male came to OPD with 

C/O pedal edema 

C/O sob grade 2-3 

History of present illness 

A 51Y old male who was toddy claimer by occupation 

his daily routine is to climb a tree and claim toddy and sell it to people until 2 years back when he started having leg pains and went to a local doctor where he was given Pain killers (?NSAID ?Ibuprofen) which he started to take it for 1 year 3 tablets a day.

An year back from today he got pedal edema , vomitings , facial puffiness,vomitings and was taken to nakrekal where they told him he has kidney problem (?AKI) and they took him to hyderbad from there for further care where he was put on medications.The patient used the medications for 6 months and suddenly stopped it as he felt he was alright and doesnt have the need to use medication and consumed alcohol on occasion of a festival and his appetite also decreased gradually.

After 1 week he started having pedal edema ,Sob ,facial puffiness and was taken to hospital in hyderabad where they advised him for dialysis.


Past history : 

Patient was diagnosed with hypertension recently 

and patient has no history of DM


Family history : 

no significant family history 


General examination :

Patient is concious , coherent,cooperative and well oriented to time and place 

Bp:140/90

Pr:92

temp :98.6F

spo2-98% at RA

Grbs -126mg%

Systemic examination:

CVS : 

S1 S2 HEARD 

NO thrills and murmurs 

RS : 

BAE +

NVBS + 

Per abdomen :

Soft,non tender 

No palpable mass 

Bowel sounds +

CNS :

NFND


Provisional diagnosis : CKD on MHD


 9 Dialysis done until now 

31/10/21-1st

2/11/21-2nd

5/11/21-3rd

9/11/21-4th

14/11/21-5th

17/11/21-6th

20/11/21-7th

22/11/21-8th 

25/11/21-9th









                   ECG👇

            


ULTRASOUND REPORT 👇




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