GM case-6

August 24,2022
Case scenario.......

Hi, I am P.kathyayani, 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:
44 year male resident of kattangur 

Chief complaints:
cough with sputum,decreased urinary output and shortness of breath (SOB),orthopnea, paroxysmal nocturnal dyspnea since 1 month, on dialysis since 1 year





HISTORY OF PRESENT ILLNESS:
One year ago patient has gained weight,SOB,pedal oedema then he was diagnosed with CKD and  he is on dialysis since then,weekly once.













ASSOCIATED DISEASES:
Hypertension since 3 years 
Diabetes since 10 years





PAST HISTORY:
Appendicitis 15 years back


PERSONAL HISTORY:
Married
Diet:veg
No appetite
No allergies
No addictions
Micturition: normal
Bowel: regular 





FAMILY HISTORY:
His father is diabetic,and died due to kidney failure



DRUG HISTORY:



GENERAL EXAMINATION:
Pallor:yes
pedal edema:yes
No lymphadenopathy
No icterus
No clubbings of fingers 




VITALS:
Temperature: 98.6 F

Pulse: 88 beats per minute

Respiratory rate: 14 cycles per minute

Blood pressure: 110/80 mm of Hg

SPO2: 98%
GRBS:160 mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
No murumurs
Cardiac sounds: S1, S2 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid 
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:
Pathology investigations:
Microbiology investigations:

PROVISIONAL DIAGNOSIS:
CKD with MHD

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