GM elog 5

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

60 YR OLD MAN UNABLE TO SPEAK

CHIEF COMPLAINTS :

• Increased abdominal pain since 10 days
• SOB since 10 days
• Unable to speak since 2 days


HOPI:

• Apparently pt was asymptomatic 6 mnths back
• Then he developed puffiness of face, pedal edema, abdominal pain, back ache, fever, burning micturition for which he visited a local hospital. 
• He got diagnosed with renal calculi and also shrunken kidneys for which he took medications and got relief. 
• Since 10 days, he again developed increased abdominal pain and SOB
• Also couldn't speak from 2 days

PAST HISTORY:

• k/c/o renal atrophy/shrunken kidneys since 6mnths
• NSAID abuse since 20 yrs for stomach ache ( due to bloating and gas as said by the pt) 

PERSONAL HISTORY:

• Farmer by occupation
• Appetite lost
• non vegetarian
• Bowel habits irregular
• micturition - burning micturition
• Addictions - beedi since 40 yrs 



FAMILY HISTORY :
Nil significant

GENERAL EXAMINATION :

Pallor - present
Oedema of feet - yes
Cyanosis, clubbing, lymphadenooathy, icterus, malnutrition - no




VITALS :

Temp - febrile
PR - 118bpm
RR - 30cpm
BP - 110/80mmHg
SPO2 - 98%
GRBS - 116mg%



SYSTEMIC EXAMINATION :

CVS:

S1, S2 heard
No thrills, no murmurs


RS:

Dyspnoea present
No wheeze
Trachea central
Breath sounds vesicular
No adventitious sounds

P/A:

Distended
No tenderness, palpable mass


CNS:

Conscious
Speech - no response
No signs of meningeal irritation


PROVISIONAL DIAGNOSIS :

AKI ON CKD


INVESTIGATIONS :


29/8/2022















1/9/2022







★Rx



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