A 41 year old male patient with left loin pain.

Hi, This is jagruthi and geetika 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio


A 41 year old male patient who is a resident of ismapelli plumber by occupation came to the opd with the

CHIEF COMPLAINT:

fever since 4 days 

left loin pain since 4 days


HISTORY OF PRESENT ILLNESS:

patient was apparently asymptomatic 6 months back then he developed loin pain ( cause unknown) went to a local hospital and got treated ( treatment given -unknown) .

then 4 days back he developed fever which was continuous high grade not associated with chills ,rigor, convulsions and skin rash.and not relieved on medication (dolo) after which he had 2 episodes of vomiting which is non projectile ,non bilious .

he had pain in left lumbar region since 4 days which is dragging type of pain insidious in onset no aggravating and relieving factors .


PAST HISTORY:

diabetic ( type 2) since 10 years under medication and is under control.

medication (oral drugs- name and dose unknown)

not a known case of HTN , epilepsy , asthma ,TB ,leprosy 




PRESENT HISTORY:

appetite - normal

diet - mixed

bowel and bladder - regular

sleep adequate - adequate

addictions - occasionally alcohol 



DAILY ROUTINE:

patient was a plumber of 41 year old 

events in life:- when he was 25 that is 16 years back he was married. After 3 years of marriage he went to hospital for infertility and some medication was taken ( medication included both herbal and generic) which he used for 6 months continuously and then irregularly for 7 years .

10 years back he went to a hospital for general checkup where he got diagnosed with DM (type 2) and is taking medication since then.


FAMILY HISTORY:

no significant family history


ALLERGIC HISTORY:

not allergic to any kind of drugs or food.

OCCUPATIONAL HISTORY:

he is a plumber

GENERAL EXAMINATION 

patient is conscious co operative and well oriented towards time place and person.

well bulit and well nourished

VITALS:

temperature:-Afebrile

pulse rate :-74 bpm

respiratory rate:-20 cpm

B.P :-130/80 mm Hg

GRBS:- 204 mg%


B.M.I :-?


no pallor icterus cyanosis clubbing lymphadenopathy and edema.




INVESTIGATIONS:

LFT:-


ELECTROLYTES:-

SERUM CREATININE:-on 12/07/22

BLOOD UREA:- 

BLOOD SUGAR:-


SERUM CREATININE:-on 14/07/22


HEMOGRAM :- 


CBP:- on 12/07/22



2D ECHO :-


USG :- 













DIAGNOSIS:

Acute kidney injury on CKD

polycystic kidney disease with diabetic since 10 years.

















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