Gen med e log

 Hi, This is M.Easha chandrika, a eight 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.

A 70 YRS OLD WITH CHRONIC RENAL FAILURE 

Chief complaints:

for dialysis 

HOPI :

Patient was apparently asymptomatic 8months ago then he developed difficulty in breathing and pedal edema.

Then he was taken to hospital and was diagnosed with renal failure.

HISTORY OF PAST ILLNESS:

k/c/o:HTN-since 10yrs

k/c/o: DM since 10 yrs

PREVIOUS HISTORY:

He was on dialysis for 10 times till date.

TREATMENT HISTORY: 
TAB.LASIX-40mg PO/BD
TAB.NICARDIA-20mg PO/TID
TAB.ARKAMINE-0.1mg PO/BD
TAB.ECOSPIRIN-75/10 PO/OD
TAB.NIDOSIS-50mg PO/BD
TAB.OROFER-XT PO/BD
INJ.EPO 4000V-SC weekly once
INJ.HAI SC/TID
Salt restriction-<2g per day

PERSONAL HISTORY:

Appetite:normal

Diet:mixed

Bowel and bladder:regular 

Sleep: adequate 

No addictions

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious and coherent

Moderately built and moderately nourished

Well oriented to time, place and person. 

No pallor

No Icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

Oedema of feet -yes

No malnutrition 

No dehydration 

VITALS:

Temperature-98.8F

Pulse rate- 80/min

Respiratory rate- 24 cycles/min

BP- 150/90mmHg

SPO2 - 98% 

GRBS-107mg/dl 

CARDIOVASCULAR SYSTEM 

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

BAE+

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit

Reflexes 

Biceps Triceps Supinator Knee Ankle  

Right + + + + +           

Left + + + +

INVESTIGATIONS:

Fluid restriction-<1.5l per day










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