general medicine 1

 This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

 

A 68yr old male resident of thirumalgheery, tailor by occupation came to our hospital with complaints of backpain since 5 days and swelling in the legs below waist.

History of present illness:-

Patient was apparently asymptomatic from past 3 yrs ago and noticed backpain and has sweepings below waist to both lower limbs 

History of past illness:-

 

Patient has undergone open heart surgery and has stent placed.

Patient is hypertensive and diabetic since 15 yrs and is on medications for the conditions.

Patient has no history of radiation exposure, epilepsy, tuberculosis.

History of CKD,CAD

Personal history:-

Patient consumes mixed diet.

Patient has normal appetite.

Patient is having regular bowel and bladder movement.

Patient sleeping pattern is irregular and has shortness of breath.

Patient has habit of smoking and alcohol.

Familial history:-

No familial history of resemblance of similar condition.

General examination:-

On examination patient was conscious, coherent, cooperative and has no Pallor, icterus, cyanosis, clubbing, lymphadenopathy and Edema. 

He had no signs of dehydration 

He was afebrile with bp of 110/80mmhg, Pulse was 98bpm, Respiratory rate was 22 cpm and his spo2 was 99% on room air and his grbs was 115mg/dl 

His systemic examination findings were 

CVS - S1, S2 heard and no murmurs 

RS - Bilateral air entry present with normal vesicular breath sounds.

His abdomin was scapoid in shape with no tenderness, papalable masses, bruits and organomegalies 

His CNS examination was normal 

Has mild bilateral pedal oedema .

Investigations

Complete blood picture:-

Serum electrolytes(Na,K,Cl):-

Serum iron:-

 

Serum creatinine:-

Blood urea:-

PROVISIONAL DIAGNOSIS:

Chronic Renal failure