A 48yr old male with vomplaints of vomitings

 Hi,I am N.Rohith (roll no 79) 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 complaints of vomitings.

Chief complaints:-

The patient came to the general medicine op with chief complaints vomitings since 4 days

History of present illness:-

The patient was apparently asymptomatic 1 month back.Then he developed neck,back(pelvic),lower limbs pain of dragging type for which he came to kims hospital.The pain got aggrevated on work and got relived on rest. RFT was done and patient was advised to undergo  dialysis. But the patient then ignored and did not undergo dialysis. 4 days back the patient had few episodes of vomiting after eating,which is non projectile,non bilious and didn’t contain any blood,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 
Weight loss-Significant 
Sleep- normal
Bowel Movement’s - regular
Addictions: alcohol (occasionally)
Micturation -normal

Family history :
Father is diabetic 

Treatment history:
 Diabetes

PHYSICAL EXAMINATION 
GENERAL EXAMINATION:
No Pallor
No icterus
No cyanosis 
Clubbing of fingers-present 
No lymphadenopathy 
No Oedema of feet 
Mild malnutrition 
No dehydration 



VITALS:
Pulse rate : 82/min 
Respiration rate : 16/min 
BP : 130/80 mm/hg 
SPO2 at room air 98%
Treatment:





PROVISIONAL DIAGNOSIS :-
CHRONIC RENAL FAILURE

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