GENERAL MEDICINE

GENERAL MEDICINE 

February 28,2023

GM CASE 3

Monday,28 February 2023

28 February 2023

CASE Scenario.....

Hi ,I am G Sukanya, 3rd bds student.This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio 

                  CASE HISTORY

Patient details 

A 50 years old male  Resident of chityala presented with

Chief complaint of

Decreased urine output since 1 week 

History of present illness

Patient was apparently asymptomatic 1 week back,then had Decreased urine output and constipation from 1 week and brought to hospital for Daignosis and treatment.....

History Past illness

1)5 years back he came to the hospital because of bloody stools and discomfort or pain and swelling in anal region and Daignosed as external Haemorrhoids. 

2)He was daignosed with Hiatus Hernia 12 years back because of severe pain near the oesophageal end while Eating and  had undergone surgery immediately.....

3) 12 years back he was daignosed with Daibetes mellitus during tests that are done before hiatus hernia surgery .

4)Hypertension from 6 years, daignosed during normal medical check up and he was not using medication properly...

Personal history 

Occupation:politician 

Diet:mixed diet 

Apetite:loss of apetite 

Sleep:inconvenience in sleeping 

Bowel:Irregular since 1 week and before he had bloody stool due Haemorrhoids 

Micturition :Decreased urine output from 1 week

Habits:Alcohol consumption 

Family history 

Diabetes:No

Hypertension:No

Heart disease:No

Tuberculosis:No

Asthma:No

Drug history

General examination 

Built:Normal Built 

Nourishment:Good 

Consciousness:in Conscious

Pallor:No pallor

Icterus:No

Cyanosis:No
Clubbing:No

Lymphadenopathy:No

Oedema:No Oedema 

 Vitals

Pulse rate:90bpm

Blood pressure:140/90mmHg

Negative Report 

He didn't have edema and  there was no symptoms of breathlessness or any other symptoms and there is only Decreased urine output,As for my assumption it may be due to obstruction in urinary tract / kidney or Renal atherosclerosis .

             -----PROVISIONAL DAIGNOSIS-----

       RENAL CALICULI/NEPHROLITHIASIS 

                               OR 

              RENAL ATHEROSCLEROSIS

       Patient Family

  Patient signature

Q/A

1) what is the Reason for Decreased urine output?and how it can be treated?

2)Are there any long term consequences of having a kidney stone?

3)What can I do to decrease my risk of having kidney stones?

5) How many days will it take to get rid of Anuria?

6) Is there any chance of getting Urinary tract infection due to obstruction in urinary tract or kidney ?

7) How is the Renal atherosclerosis is related to Decreased urine output ?