64 year old male patient with chief complaint of injury at right little toe and shortness of breath

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 patients 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 comment box is welcome .

A 64 year old male patient  resident of nalgonda retired rtc employe by occupation presented to opd with a chief complaint of injury at right little toe and shortness of breath 

HISTORY OF PRESENT ILLNESS 
11 days back he got injured on a cc road ..on the he got hit his right little toe by sharp stone while walking 
Next day after injury his toe got swelling to posterior direction 
Later he visted to local doctor on investigations got reported about kidney problem 
He has shortness of breath 8days back which was subsided by proper oxygen supply to his respiration 
He complains of pain in the abdomen since last night which is now persisting at low level in the morning...
He complains of decrease in urine output since 8days 

PAST HISTORY 
Diabetic since 6 years 
Bp since 10 years 
Skin alergy at little toes 

FAMILY HISTORY 
No significance 

PERSONAL HISTORY 
mixed diet 
Alcoholic :- 90ml per day 
Smoking :-daily 10 cigarettes per day

GENERAL EXAMINATION
 
 No pallor 
No clubbing
No icterus 
No cyanosis

Vitals 
Temp 98.4
Pulse 86 b/m
Respiration rate 18 times 
Bp 160/90



SYSTEMIC EXAMINATION 

CVS s1 and s2 are heard 
CNS  speech is normal 
Respiratory system :-

Per abdomen
No fluid present 
No palpable mass
 
Palp abdomen 
Liver not palpable 
Spleen not palpable 

Reddish rash is observed arround the waist region 

PROVISIONAL DIAGNOSIS 
Acute kidney disease maintenance on hemodialysis

INVESTIGATIONS




.



Comments

Post a Comment

Popular posts from this blog

55 year old male with chief complaint of generalised weakness since 3 days and loss of appetite

Image
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 patients 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 comment box is welcome  55 year old male patient resident of nalgonda ironing clothes by occupation presented to opd with the chief complaint of generalised weakness and loss of appetite HISTORY OF PRESENT ILLNESS Loss of appetite :- since 25 days  He complains of feeling of vomiting sensation on tasting any food  He tastes bitter on eating any food in whole day  Generalised weakness :- since 3days  Patient complains of backache while trying to get up from bed He complains of cough with sputum since 5day
Read more

50 year old female patient presented to opd with a chief complaint of shortness of breath and bipedal edema since 15 days

Image
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 patients 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 comment box is welcome . 50 year old female patient labour by occupation resident of kodada presented to opd with a chief complaint of shortness of breath and bipedal edema since 15 days  HISTORY OF PRESENT ILLNESS She was asymptomatic 1 year back and later she developed bipedal edema which was recurrent even on medication prescribed by local doctor  Since 15 days she complains of bipedal edema  which is geting relieved while resting and agravating while walking    She  complains of shortness of breath w
Read more

46 year old male patient presented to opd with chief complaint of shortness of breath and bipedal edema

Image
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 patients 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 comment box is welcome . A 46 year old patient from miryalguda tailor by occupation  presented to OPD with chief complaint of bipedal edema since 2 months and shortness of breath since 2months HISTORY OF PRESNT ILLNESS patient was asymptomatic 3 years back and later developed edema in legs and it was subsided because of medication prescribed by local doctor Before 2 months from present he again developed edema in legs and visited local doctor on investigations of urine examination doctor prescribed to ta
Read more