General Medicine elog 5

22-06-22
Hi I am Swetha, 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.This also reflect my patient centered online learning portfolio.
Chief complaints: A 65 yrs old male patient who was farmer by occupation resident of Nalgonda district came with complaints of SOB, decreased appetite, constipation, burning micturition,and decreased sleep
HOPI: The patient was normal 9 yrs  back ,then developed hypertension ; dailysis was done in August 2021 . Now presented  with  SOB, decreased appetite and sleep since 10 days,backpain non radiating type, constipation since week , burning micturition since week ,fever 4 days ego and yesterday night which was not associated with chills ,rigor.
No history of cough ,cold ,chestpain,
Past illness
Hypertension: since 9 yrs on medication
Seizures: 4 yrs back 
CKD :  8 times dailyasis was done 9 months ago( August ) ,and on medication
Personal history: married, non-vegetarian diet, abnormal micturition, irregular bowels,no known allergies ,
Occasional alcoholic
Smoking
Family history: 
No history of diabetes,HTN,heart disease, stroke,cancer ,TB, asthma
General examination:
Pallor present
No icterus, cyanosis, lymphadenopathy clubbing of fingers and toes, oedema
P.R: 76/min
RR : 24 cpm 
BP: 130/70
Spo2 : 96%
Systemic examination:
CVS : no thrills
Cardiac sounds present
No cardiac murmur
RS: Dyspnea present
Position of trachea central
Breath sounds vesicular
CNS : conscious coherent cooperative 
  Speech : normal
Investigation:
CBP, urea creatinine, electrolytes, CUE,LFT,
Diagnosis : CKD ,CAD, seizures ,HTN
Treatment :
Fllow back 


1 st dialysis : 23-06-22
2 nd dialysis: 25-06-22
3 rd dialysis :28-09-22

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