Case history 1
This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
A 50 years old male patient presented to the opd with chief complaint of swelling of lower limbs, decreased urine output and shortness of breath since 1 year.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1year ago, then developed pedal edema and shortness of breath.
1 year ago patient had recurrent fever for which he visited the hospital, where he diagnosed as chronic kidney failure and undergone hemodialysis 3 times. Later presented to KIMS for further evaluation.
The patient had low grade fever and neck pain.
PAST HISTORY
Patient had a fracture of right lower limb 6 years ago for which he took local ayurvedic treatment.
There is no history of any major surgeries.
K/c/o hypertension
No history of diabetes, T.B, Asthma, CAD.
PERSONAL HISTORY
Patient consumes mixed diet.
Normal bowel and bladder movements.
He had adequate sleep.
Patient is non alcoholic, quit smoking 4 years ago.
FAMILY HISTORY
No history of similar complaints in any of the family members.
TREATMENT HISTORY
Patient took treatment for kidney failure in the previous hospital.
No history of drug allergy.
GENERAL EXAMINATION
Patient is conscious, coherent and co-operative. Well oriented to time, place and person. Normal built and nourished
There is bilateral pedal edema (pitting type) and pallor.
No history of cyanosis, clubbing, icterus.
No generalised lymphadenopathy.
Vitals
Temperature:99°f
Respiratory rate:22 cycles/min
Pulse rate:100 beats/ min
B.P:140/90mm hg
SpO2:96%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engoreged veins, scars, sinuses.
Palpation:
JVP:normal
Auscultation:
S1, S2 are heard.
RESPIRATORY SYSTEM
Bilateral airway+
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
abdomen is scaphoid shape
Non-tender
No palpable mass or free fluid.
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
INVESTIGATIONS
Pallor:
Tab NICARDIA 20 mg
Tab PANTOP 40 mg
Tab LASIX 40mg
Tab Bio - D3
Tab OROFER
Tab NODOSIS
Tab SHELCAL 500mg
Tab ULTRACET
Blood transfusion on 11/08/2021
Comments
Post a Comment