General Medicine e-log1

General Medicine e-log 1

June 06 2022

Hi , I’m Shreshta Reddy (roll no.6) 3rd sem medical student. This is an online e log book to discuss our patientd health data after taking her consent. This also reflects my patient centered online learning portfolio.

An 84 year old male, farmer, resident of nampally mandal, was admitted in the hospital on Tuesday (Dt. 02-06-22) With complaints of anuria since 8 days. He suffered from fever, the night before admission.

History of present illness :

Onset.          : insidious 

Progression : gradual

Fever :          - high grade

                    -chills,rigors

                    -no cough, no cold

Vomitings : 1 time (food)

Pedal edema- pitting type.

SOB - absent.

Burning sensation only while passing urine

Past history :

The patient has donated his left kidney to his brother who was suffering from sudden renal failure 40 years ago (in 1983). 

10 years ago, the patient has suffered from similar problem (anuria) . He was admitted into a local government hospital and underwent 2 dialysis. 

He has been using BP tablets since 10 years.

He underwent 3 dialysis after admission into the hospital, last dialysis being done on 4th june. 

Family history: 

Brother suffered from sudden failure of both the kidneys, received a kidney from patient, died 5 years after the transplantation, suffering from jaundice. 

Diet.            : mixed

Appetite.     : reduced 

Sleep.          : adequate 

Addictions. : Beedi childhood, stopped after kidney transplantation.

Bowel/Bladder:  Constipation , Oliguria

General Examination : 

Moderately built

Moderately nourished

Pallor was present 

No icterus

No cyanosis 

Pedal edema of pitting type was present 

No clubbing of fingers