A 52 yrs Old male patient farmer by occupation resident of suryapet came to old with complaint of vomiting on and off from 4 months reduced appetite bilateral pedal oedema since 4 months burning micturation from 4 months

 

Hi ,  I am Nithin Maridi (roll no :82) 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.


Chief complaints 


A 52 yrs Old male  patient farmer by occupation resident of suryapet came to old with complaint of vomiting on and off from 4 months reduced appetite bilateral pedal oedema since 4 months burning micturation from 4 months 


Pt was apparently asymptomatic 4 months back then developed vomiting 6-8 episodes a day 


History of present illness


Bilateral pedal odema pitting type gradually progressive 


Decreased appetite 


No history of hematuria fever and dyspnonea


History of past illness


Know case of diabetes mellitus hypertension ckd 


Medications not know


Personal history 


Occupation daily labourer 


Diet:mixed


Bowels irregular


Appetite decreased 


Micturation irregular


Sleep:normal


No known allergies 


Habits:alcohol taken regularly 

FAMILY HISTORY 


 Diabetes - yes


Hypertension -yes


Heart disease - No


Stroke - No 


Concern - No


Tuberculosis-no


Asthma - No


General examination 


No pallor 


No icterus 


No cyanosis 


No clubbing of fingers


No lymphadenopathy 


pedal odema 












SYSTEMATIC EXAMINATION:


B. CARDIO VASCULAR SYSTEM


1. Thrills No 


2. Cardiac Sounds


3. Cardiac murmurs No 


C. RESPIRATORY SYSTEM


1. Dyspnoea - No


2. Wheeze - No 


3. Position of Trachea - Central


4. Breath Sounds - Vesicular


5. Adventilious Sounds - No


D. ABDOMEN


1. Shape of abdomen - Scaphoid 


2. Tenderness - No


3. Palpable mass - No 


4. Hernial Orifices Normal 


5. Free Fluid No 


6. Bruits No 


7. Liver - Not palpable


8. Spleen - Not palpable 


9. Bowel sounds -Yes


Reflexes  normal


Cerebellare signs


Finger nose coordination no


Knee heel coordination no

Investigation 

Investigation 














Provisional diagnosis:chronic kidney disease with known case of diabetes mellitus and hypertension

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