GM e-log

 This is online E log book to discuss our patients health data shared after taking his guardians informed consent form


I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findingsfindings investigations and come with a diagnosis and treatment plan. .
A 65 yr old male came to OPD with chief complaints of a Decreased urine output and Abdominal distension since 1 day Bilateral lower limb swelling which is pitting type since 10 days 

History of present Illness:-
-Known case of Decreased urine output, abdominal distension, not associated with pain. Bilateral pitting type since 10 days.
History of low grade intermittent fever not associated with chills, rigors since 10 days.

History of past Illness
4 Cycles of Haemodialysis done
Known case of Hypertension and Diabetes

Treatment history
Medication using for Diabetes since  5 yrs
Personal History
Diet : mixed
Appetite: losed
Bowel movement: losed
Micturition: Abnormal
Addictions: occasional Alcohol consumption, Smoking
Family history 
No relavent family history
General Examination 
Patient is conscious,coherent and co operative well oriented with time and place .
Well nourished and built

There are no signs of
Cyanosis
Lymphadenopathy
Clubbing
There is presence  of 
Pallor 
Oedema present 10 days back ,subsided now
VITALS
Temperature: 98.6  degree Fahrenheit
Pulse rate: 86 per min
Respiratory rate: 18 per min
BP: 130/80 
SpO2: 96% 
Systemic Examination
CVS
S1 S2 heared
No murmurs

RESPIRATORY system 
Dyspnoea : no
Wheeze : no
Postion of trachea: central

ABDOMEN 
No Tenderness
There is no free fluids
Liver and spleen is not palpable
Bowel sounds are normal

CNS
Conscious with normal'speech
There is no sign of meningeal irritation
Glasgow scale 15/15



Investigations

USG 

HBsAg

HIV 1/2 Rapid test

Anti HCV ab


                   Blood sugar
  
                 Blood urea
               
           Serum creatinine 


              Serum electrolytes

Diagnosis:
CKD with hypertension and DM

Treatment
4 cycles of hemodialysis done

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