GEN MED E-LOG
Hi, This is Vaishnavi Manga, 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:
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:
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