This is an online e log book to discuss our patient de-identified health data shared after taking his /her guardian signed informed consent. Here we discuss our individual patients problems
with collectors current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
1 have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 50 year old male farmer by occupation resident of Nagakurnool came to the hospital for dialysis
CHIEF COMPLAINTS:
The Patient came to the hospital for dialysis
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 8 months back
He then developed severe back pain which was insidious in onset After a month he then suddenly fainted when he was in his field .
When he went to the hospital he was given medication which haven't helped him much .after 1 month he was diagnosed of renal failure and had a fistula in his carotid triangle of the right side of the neck after few days there was infection in that region so the fistula was kept in his left hand . then he started getting regular dialysis in KIMS Narketpalli weekly twice from 6 months
DAILY ROUTINE :
He wakes up between 5:00 AM to 6:30 AM. He then brushes his teeth goes to washroom and gets bath and have rice and dal as his breakfast at 8:00 AM. He goes to the field with his tractor at 9:00 AM . He then has his lunch at 1:00 PM Then he again goes to work and return to home at 5:00 to 6:00 PM and has dinner at 8:00 PM and sleeps at 9:00 PM .
On the day of incident after he had his breakfast and went to the field where he suddenly fainted . His son brought him to the hospital where he was diagonsed of renal failure .
PAST HISTORY :
K/c/o Diabetes from 20 years and hypertension from 6 months
He had severe back pain 8 months back ( before he became unconscious) and also had UTI and burning micturition
N/k/o- TB,epilepsy, thyroid abnormalities,asthma
PERSONAL HISTORY :
Diet - Mixed appetite- inadequate Sleep and SOB on sleeping
Has constipation and indigestion from 2 months and bladder movement - Normal
He left smoking 3 months back
No allergies
FAMILY HISTORY :
His mother had diabetes and hypertension
GENERAL EXAMINATION :
prior consent was taken and patient was examined in a well lit
room
patient was conscious ,coherent and cooperation
pallor present , No icterus, clubbing, cyanosis
No generalised lymphadenopathy
No pedal edema on dailysis
He has fever and chills during dialysis
INVESTIGATIONS :
I
Ultasound shows he has cysts in his left kidney
PROVISIONAL DIAGNOSIS :
Polycystic kidney disease - Renal failure
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