General medicine elog



This is an online E - log book to discuss our patients de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.

A 51 year old male resident of Aliya came to our hospital for regular dialysis

History of present illness 

Patient was apparently asymptomatic 6 months back then he had 1 episode of seizure for which he was admitted in our hospital about 10days where he was incidentally diagnosed with hypertension.After 2 months he developed pedal oedema which increased on walking ,shortness of breath insidious in onset and gradually progressive ,grade 3 .

History of orthopnea is present 

 History Paroxysmal nocturnal dyspnea present 

History of cough and cold

Decreased urine out put since 1 month,poor flow.

Burning micturation present and also complained about 

 increased frequency of urine and urgency 

No history of fever and investigation showed increased serum creatinine level .

He is undergoing dialysis since 20 days.


Past history 

Know case of Diabetes mellitus since 20 years and hypertension since 6 months 

He is on regular medication 

Not a known case asthma ,Tb , cardiovascular diseases

Personal history 

Diet -mixed

Appetite decreased 

Sleep inadequate

Bowel and bladder movements regular

Addictions: alcoholic but he stopped taking alcohol since 8 years 

He was taking tobbaco since 30 years.

Family history 

Not significant

General examination

Patient was conscious ,coherent and well oriented to time and place

Patient was moderately built and nourished 


Vitals

Pulse: 80beats/min


Bp: 140/90mmof Hg


Temperature: afebrile


RR: 16cycles/min





Pallor is absent 


No icterus,cyanosis,clubbing,lymphadenopathy






Systemic examination

CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard

Provisional diagnosis

Chronic kidney disease

Investigations 












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General medicine elog

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 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 29 year male came to opd with chief complaints of  Bilateral pain in lower limbs upto knee since 20 days HOPI Patient was apparently asymptomatic 3 years ago then developed severe sudden pain in
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Image
This is an online E - log book to discuss our patients de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online portfolio and your valuable inputs on the comment box.  A 42 year old male , resident of Choutupal Who is daily wage labourer by occupation came to opd for regular dialysis. History of presenting illness: Patient was apparantly asymptomatic 1 .5yr back  Then after taking covid vaccination he developed fever Fever was present through out the day  Not associated with vomitings,nausea,burning micturition . Generalised weakness was present  Didnt relieve on taking medication also  So he visited our hospital. Then he was diagnosed with hypertension and re
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