GENERAL MEDICINE

Hello all this is K. Rohit  ,a fifth semester student.This E Log depicts the patient centered approach to learning.

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Cheif  complaint

A 64 year old male patient came to medical OPD with chief complaints of pain in right loin since 1 month and vomiting since 1 month and burning micturition Since 1 month .

History of presentings illness

Patient was apparently asymptomatic 10 years back and then developed pain in the right loin for which he was diagnosed to have renal stones and operated for it . Then 3 years later again he have experienced Bilateral loin pain and diagnosed with Bilateral kidney stones and then underwent for surgery for kidney stones . 

Then 4 years back he have developed a swelling in front and middle of abdomen for which he was diagnosed as having hernia and Operated for it. 4years back he developed abdominal pain and diagnosed as having intestinal ulcer for which he treated .And at the same time he was diagnosed to be having Diabetes and Hypertension.

Then 1 year back he went to the hospital with complaints of generalised weakness and SOB on exertion this was due to reduced Hemoglobin.Then he has experiencing right loin pain and vomiting since 1month.

History of past illness

K/c / o DM and Hypertension

for Hypertension he was not using any medication

Not a K/c/o TB, asthma,epilepsy

Treatment history

He was on Diabetic Medication

NO history of use of any other medication

Family history

There is no significant family historys

personel history

Mixed diet

Normal Appetite

Bowel and B ladder movements are Normal

NO known allergies

Adequate sleep

Habits

Occasionally consumes alcohol

cigarette Smoking 20 years back 1 pack per day

Daily routine

He generally wakes up at 5 o clock in the morning and does daily work of home.At 7 o clock he has his Breakfast and after some time he goes into the village and Chit chat with neighbours .At 1 o clock he take his lunch and take nap for atleast 2-3 hours.He do not have any habit of drinking tea in the evening.At last he will take his dinner at 8 o clock and then goes to bed. 

General Examination

on Examination patient is conscious,coherent,co - operative and well Oriented to time,place and person.

There are no signs of

Icterus,cyanosis,clubbing,Lymphadenopathy and oedema

There is presence of mild pallor 

Vitals 

Temp:99:6 F

pulse rate:88 bpm

Bp:160/70 mm Hg

Resp rate:16 / min

systemic examination

C VS: No thrills

S1 and S2 +

NO murmurs

Respiratory system

NO Dyspnoea

NOWheeze

Trachea is centrally located

Abdomen

soft and non tender

NO palpable Mass

Liver and Spleen are not palpable

CNS

No abnormality detected 



PROVISIONAL DIAGNOSIS

Renal stones 

INVESTIGATIONS 


USG

Right moderate hydrouretero nephrosis

NCCT

Right kidney is enlarged,there is dilatation of pelvicalceal System

Left kidney normal.

Right mid ureteric calaulus causing proximal hydroureteroneprosis.

Diagnosis

Obstructive uropathy with Acute kidney injury

Treatment

T. Lasix

T Nodosis

T shelcal 

T. orofer 

T Nicardia

on 22/7/22

BP:160/80 mmHg

PR: 82 bpm

C V S: SI and S2 + 

Resp rate: 14 cpm

CNS: NAD 

Treatment Continued

on 23/7/22 

BP: 110/70 mm Hg

PR: 84 bpm

CVS: SI and S2 + 

CNS: NAD 

P/A . Distended

on 24/7 /22 

BP: 100/70 mmHg 

PR:: 82 bpm 

CVS:SI and S2 + 

CNS: NAD 

Resp rate: Normal

on 26/7/22

BP: 140/80 mm Hg 

PR: 80 bpm

cvs:S1 and S2 + 

CNS: NAD 

P/A:soft and nontender




 




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