GENERAL MEDICINE E-LOG 2


A 23 YEAR OLD MALE BORN WITH SINGLE KIDNEY [renal agenesis]

HI,Iam Harichandanarao 3rd sem medical student.This is an online elog book to discuss our patient's health data after taking his consent.This also reflects my patient centred online learning portfolio

A 23 yr old umnarried man mechanic by occupation resident of nalgonda has already undergone 3 dialysis in the past came for further management and treatment.

HISTORY OF PRESENT ILLNESS:

Patient was asymptamatic 2 year back he didn'nt even know that he was born with a single kidney.one day SUDDENLY  he got severe chest pain at 9pm he consulted a local rmp and used medication he was normal for an hour and again felt pain in his chest at 12 am then he went to a local doctor in nalgonda and they diagnosed that he was boen with only one kidney and that kidney was affected due to the lack of equipment they sent him to hyderabad for hemodialysis and after 3 hemodialysis he came to our hospital for further managemnt and treatment on 20th may 

he is complaining dry cough since 12 days his urine output is normal with burning micturitiontill now he had sialysis for 8 times in our hospital.

the last time he got dialysis he is suffering from severe pain in the left side about 4cm below the nipple 

 

and during dialysis he suffered from severe asthma on june 9th and he was asked to stay under observation for three more days this is the first time he got asthama during dialysis.

no case of hypertension,diabetes,food allergies,tuberclosis

pain in the right side infraclavicular region after dialysis while talking 

suffering from fever since 2 days and burning micturition whenever he gets fever

HISTORY OF PAST ILLNESS:

No history of past illness

FAMILY HISTORY:

no family history and sibling history

PHYSICAL EXAMINATION:

Pulse rate:84beats /min

no pallor,icterus,lymphadenopathy

PERSONAL HISTORY:

tobacco and alcohol habit since 6 years

mixed diet

SYSTEMIC EXAMINATION:

CARDIOVASCULARSYTEM;

no thrills and murmers

s1 and s2 sounds heard

CNS:

conscious,normal speech no neck stiffness 

INVESTIGATIONS:

 


 






TREATMENT:

tab.lasix

tab.orofer

tab.shelcal

tan pan

inj.erythropoitin

fluid restriction leaa than 2l/day

salt restriction less than 2gm per day

 

 



Popular posts from this blog

GEBERAL MEDICINE ELOG-12

HI,Iam Harichandana of 6thsem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio A 67 yr old patient came with cheif complaints of abdominal tightness within 10-15mins after eating since 4 days HOPI  Patient was apparently asymptomatic 4 days back then he developed abdominal tightness associated with shortness of breath relived by itself with 3-4 hrs on rest,no aggravating factors Non pitting type of pedal edema is present Subcutaneos swelling in the paraumbilical region No history of constipation,belching,burning micturition fever PERSONAL HISTORY: diet-mixed Appetite -normal Sleep-adequate Bowel nd bladder normal No additions FAMILY HISTORY: no relevant family history  GENERAL EXAMINATION: Patient was conscious coherent well oriented to time place and person No pallor,icterus,clubbing,cyanosis, lymphadenopathy, Temperature-afebrile Pulse-70bpm
Read more

GENERAL MEDICINE E-LOG-11

HI,Iam Harichandana of 6thsem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio A 50 yr old female patient came with cheif complaints of fever,loss of appetite,burning sensation since 3 days HOPI Patient was apparently asymptomatic 3 days back then she developed fever which was intermittent, low grade fever,not assosiated with chills nd rigor,no diurnal variation which was relieved on medication, assosiated with reduced apetite Chest burning sensation associated with belching regurgitation of food aggravated after food intake Nausea is present No history of chest pain,sob Past history: Similar complaints present two years back  PERSONAL HISTORY: diet-mixed Appetite -reduced Sleep-adequate Bowel nd bladder normal No additions FAMILY HISTORY: no relevant family history  GENERAL EXAMINATION: Patient was conscious coherent well oriented to time place and person No pa...
Read more

GENERAL MEDICINE ELOG-13

HI,Iam Harichandana of 6thsem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects patient centred online learning portfolio A 38 year old patient came with cheif complaints of left side chest pain since 1 week HOPI: patient was apparently asymptomatic 7 days back then he developed left sided chest pain,intermittent,sharp pricking type, aggravated on lifting,working relived on medication Negative history No history of fever,nausea,vomiting,no history of burning micturition PAST HISTORY: GASTRIC ACIDITY since 10years PERSONAL HISTORY: diet-mixed Appetite -normal Sleep-adequate Bowel nd bladder normal No additions FAMILY HISTORY: no relevant family history  GENERAL EXAMINATION: Patient was conscious coherent well oriented to time place and person No pallor,icterus,clubbing,cyanosis, lymphadenopathy, Temperature-afebrile Pulse-70bpm Bp-120/70
Read more