65 years old male patient with chief complaint of decreased urine output,shortness of breath,lower back pain since 3days

 65 years old male patient with chief complaint of decreased urine output,shortness of breath,lower back pain since 3days

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.


Date of admission:17-10-2022


Chief Complaints:

65 years old male patient with chief complaint of decreased urine output,shortness of breath,lower back pain since 3days


History of Present Illness:

Patient is apparently asymptomatic 3days back then developed complaints of decreased urine output since 3days associated with SOB since 3days with is insidious in onset

No complaints of burning micturition and pedal edema



History of Past illness:


History of Diabetes mellitus and hypertension since 15yrs

No h/o asthma,tb,CAD,epilepsy,lymphadenopathy, surgery


Personal History:

Married

Diet-mixed

Appetite-normal

Bowel movement-Regular

Micturition-Decreased

Addictions- alcohol (occasionally)



Family History:

 No history of DM, CAD, Asthma and thyroid disorders in the family


General Examination:

Vitals:

Temp:99.8°f

Respiratory rate:18bpm

Pulse:78bpm

Blood pressure:140/80mmhg

Sp O2 98


Systemic Examination:

Cardiovascular system

Thrills:no

Cardiac sounds:S1,s2 sounds

Cardiac murmurs:no


Respiratory system:

Dysponea : No

Wheeze: No

Position of trachea:Central

Breath sounds: vesicular

Adventitious sounds:no


Abdomen

Shape of abdomen:scaphoid

Tenderness:no

Palpable mass:no

Henias orifices: normal

Free fluid:no

Bruits:no

 

Liver: Not palpable

Spleen: Not palpable

Bowel sounds:yes


Central Nervous system:

 Pt is conscious

Speech: Normal

Signs of meningitis:No signs

Cranial nerves: Normal

Motor and sensory system: Normal


Provisional Diagnosis:

CKD on MHD 



Investigation:

















 

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