A 44yr old man with SOB ,cough, weakness and pedal edema
August 17,2022
Case scenario.......
Hi, I am Pranavi V , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:
Chief complaints: SOB since a month , cough with sputum , weakness since a week, decreased urine output since a month
HISTORY OF PRESENT ILLNESS: Apparently the patient was asymptomatic a month ago but then started experiencing SOB and decreased urine output. He also had cough with sputum,weakness and pedal since a week. The patient has CKD is on MHD since 1 year at KIMS , Narketpalle.
ASSOCIATED DISEASES: Patient has h/o Diabetes mellitus since he was 23
H/o Blood pressure since 5 yrs
PAST HISTORY: The patient has undergone appendectomy 15 yrs ago .
PERSONAL HISTORY: The patient is from. He is a toddy drink collector.
Appetite: Decreased
Diet: Vegetarian
FAMILY HISTORY: The patient's father had a H/O Diabetes and die due to kidney damage.
DRUG HISTORY:
Tab. Nicardia 70mg
Tab. Nodosis
Tab. Arkamin 0.1mg
Inj Zofer 4mg
Tab Met -XL 50mg
Tab Metolazone 5mg
Inj Lasix 60mg
Inj PAN 40 mg
GENERAL EXAMINATION:
Pallor - Present
Right eye:
Left eye:
Pedel edema: normal ( decreased after dialysis)
VITALS:
Temperature: Afebrile
Pulse:88 beats per minute
Respiratory rate: 14 cycles per minute
Blood pressure: 110/70 mm of Hg
SPO2: 98%
SYSTEMIC EXAMINATION:
Cardiovascular system:
__no_ thrills
No murumurs
Cardiac sounds: S1, S2 ____
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular??
Abdomen:
Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious
Speech: normal
INVESTIGATIONS:
Biochemical investigations:
Pathological investigations:
Microbiological investigations:
PROVISIONAL DIAGNOSIS: Chronic Kidney Disease
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