A 70year old male patient came to the OPD with the cheif complaint of increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs
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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.
A 70year old male patient came to the OPD with the cheif complaint of increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs since 12pm on 20/11/2022.
• cheif complaint:- increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs since 12pm on 20/11/2022.
• History of present illness:-
patient was apparently asymptomatic 12 days back then he noticed decreased urine output, and involuntary movements of b/l limbs since 1day.
• History of past illness:-
k/c/o of CKD,since 20 years (regular medication)
N/k/c/o HTN,DB,TB, Epilepsy,CAD.
NSAID abuse( +)-(used NSAID'S for back pain from 2009)
• Personal history:-
Martial status:- Married
Occupation:- Farmer
Appetite -Normal
Non-vegetarian
Bowels-Regular
Micturition -Normal
No known allergies
• Habits/Addictions
Alcohol-Regular
Tobacco -No
betel nut- No
betel leaf-No
drug use-No
• Family History:
No history of DM, CAD, Asthma and thyroid disorders in the family
• General Examination:
Vitals:
Temp:99.2°F
Respiratory rate:18/min
Pulse:108/mim
Blood pressure:150/100mmhg
Sp O2 :97%
GRBS:-138mg%
• Systemic Examination:
Cardiovascular Examination:
Thrills:no
Cardiac sounds:S1,S2 heard
Cardiac murmurs:no
• Respiratory system:
Dysponea:no
Wheeze:no
Position of trachea: central
Breath sounds: vesicular
Adventitious sounds:
• Abdomen
Shape of abdomen: Scaphoid
Tenderness:no
Palpable mass:no
Henias orifices: normal
Free fluid:yes
Bruits:no
Liver:Not palpable
Spleen:not palpable
Bowel sounds:yes
• Central Nervous system:
Pt is conscious
Speech: normal
Signs of meningitis:no
Cranial nerves:normal
Motor and sensory system:normal
Central Nervous system:
• Diagnosis:-
CKD on MHD
Lichen simplex chronicos(legs)
Pytriasis versicolor(upper back)
• Investigations:-
Comments
Post a Comment