A 48 yr old patient came to OPD with complaints of vomitings.

April 24,2023
Hi,I am M.praveen kumar (roll no 63)5th semester medical student.This is an online e block to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio
A 48 year old male came to OP with severe vomitings.

Chief complaints:-

The patient complained of severe vomitings from the past 4 days

History of present illness:-
The patient was apparently asymptomatic 1 month back.Then he developed neck and back pain  for which he went to a hospital. Then renal function tests(RFT) was done and patient was told to undergo  dialysis.patient then ignored and didn't undergone dialysis.4 days back patient had few episodes of vomiting after eating ,he then visited Kims hospital where 2 rounds of dialysis was done. 

History of past illness:-
The patient is  a known case of diabetes.
Kept on medication - for 4 years.

Personal history:-
Diet- mixed
Appetite- decreased 
Sleep- normal
Bowel Movement’s - regular
Addictions: alcohol (occasionally)
Micturation -normal

Family history :
Father is diabetic 

Treatment history:
 Diabetes

PHYSICAL EXAMINATION 
GENERAL : 
No Pallor
No icterus 
No cyanosis 
clubbing of fingers -present
No lymphadenopathy 
No Oedema of feet 
Mild malnutrition 
No dehydration 
Pulse rate : 82/min 
Respiration rate : 16/min 
BP : 130/80 mm/hg 
SPO2 at room air 98%
 
INVESTIGATIONS


Treatment
PROVISIONAL DIAGNOSIS :-
RENAL FAILURE

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