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A 60 yr old male patient e log

 E-LOG GENERAL MEDICINE

Hi, This is K.Srinija , 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


★ CASE SCENARIO

 A 60 year old male patient came with
 
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
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) 



★ 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) 


★ FAMILY HISTORY

Not significant

★ PERSONAL HISTORY

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

★ 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

S1S2 heard 
No thrills and murmurs 

- RS

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

Distended




- CNS

Conscious
Speech - no response
No signs of meningeal irritation

★ PROVISIONAL DIAGNOSIS :

AKI ON CKD







★ INVESTIGATIONS




29/8/2022
















30/8/2022






31/8/2022





1/9/2022







★Rx


29/8/2022


30/8/2022




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