23 B.Divya

23 B.Divya 

3rd semester

   

   This is an online e - log platform to discuss case scenario of patient with their guardian's permission
  

   *CASE SCENARIO : 

                A 75 yr old male patient resident of Suryapet came to causality with cheif complaints of breathlessness Complaints and duration : CKD Pedal edema Facial puffiness since 3 days Shortness of breath 
 

History of present illness : 

No h/o present illness.

History of past illness : 


 CkD on MHD ( analogue to nephropathy ) 

 Treatment history :


 No h/o Diabetes
  No h/o CAD 
 No h/o asthma
  No h/o tuberculosis 
Hypertension is present 
H/o blood transfusion (1) and surgery (1) P


Personal history : 


 Loss of appetite
  Bowel movements are regular
  Micturition is abnormal 
 No unknown allergies are seen 

 Family history : 


 No H/ o of diabetes , hypertension , stroke, cancer , Tb, asthma .  


General examination : 


 Patient is pallor 
no icterus 
No cyanosis 
 No clubbing of fingers
 No Lymphadenopathy . 
Edema of feet is seen 
 No h/o malnutrition 
 No h/o dehydration 


 Vitals :

 Temperature : 98.4 F 
Pulse rate : 86 beats / min 
 Respiratory rate : 18 / min Bp : 110 / 70 S

ystemic examination : 


 CVS 

 No thrills
  No cardiac murmurs


 Respiratory system :

 Dyspnoea is seen 
 No wheezing sounds
  Position of trachea is central
  Breath sound - vesicular


 Abdominal examination : 

 Shape - scaphoid 
 No tenderness 
 No palpable mass 
 Liver and spleen - non palpable 
 Bowel sounds are present 


 CNS : 

 Patient is conscious 
 Speech normal
  No neck stiffness 
 Cranial nerves , motor and sensory system are normal 


 Provisional diagnosis :CKD ON MHD.




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