GENERAL MEDICINE ELOG.

68 year old female suffering with chronic kidney failure. 

DECEMBER 9th 2022


 Hi, I am Mattupalli Pritish Jasper 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.


A 68 year old farmer by occupation resident of chityala came to causality for dialysis


HISTORY OF PRESENT ILLNESSES

Started dialysis 15 days ago at a hospital in Hyderabad

Visited our hospital for dialysis but was admitted due to low blood pressure 

Also presented with fever when admitted but subsided with medication


PAST HISTORY 

Previously suffered with kidney problems past 10 year's ago

Normal micurition 


PAST HISTORY 

Diet mixed 

Sleep adequate

Appetite decreased

No allergies and addictions



NEGATIVE HISTORY

 

no history of tuberculosis epilepsy asthma diabetes 


TREATMENT HISTORY 

Was on medication for kidney problems for the past 10 year's 


FAMILY HISTORY

No one with similar conditions 


GENERAL EXAMINATION 

Moderately Built and Nourished.

Pallor present

Icterus Absent

Clubbing Absent

Cyanosis Absent

Lymphadenopathy Absent

Pedal edema present


VITALS


Pulse rate : 88 per minute 

B.p : 80/60

Spo :95%


CNS


Patient is conscious and alert

Normal speech


PROVISIONAL DIAGNOSIS 


Chronic kidney disease


Clinical findings





Medication














ECG 

















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