Case history 02

 General medicine Case 2

August 23, 2021

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A 72 yr old male  patient  agriculture by occupation presented to the opd with chief complaint of pedal edema , shortness of breath and decreased urine output since 20 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 yrs back. Patient complaints of shortness of breath, decreased urine output,and pedal edema since 20 days

Patient noticed the swelling in his leg and has joint pains and he visited local hospital and medication was taken at that time patient was diagnosed with diabetes and hypertension. 

After that patient patient suffers with shortness of breath and has visited to another hospital and was diagnosed as kidney disease. 6-7 times Dialysis was done. 

 

As due to low socioeconomic status patient comes to our hospital on 20/8/21 with similar complaints since 20 days

- There is history of weight loss

-There is no history of cough and fever

-patient complaints of burning micturition due to decreased urine output

- patient says that swelling has subsided by medication

PAST HISTORY

- Patient is known case of hypertension and diabetes and COPD

- There is no history of surgery

- There is no history of epilepsy,asthma,TB

- Patient gives history of blood transfusion due to blood loss 

TREATMENT HISTORY

Patient takes medicine for hypertension 10 mg clonidipine and diabetes 50mg vildagliptin

PERSONAL HISTORY

- Appetite is normal

- Diet is mixed

- Sleep is adequate

-  Decreased urine output

- Patient was alcoholic and cigarette smoker but he has stopped due to health issues

FAMILY HISTORY

There is no history of similar complaints in the family members. There is no history of death in family due to cancer

GENERAL PHYSICAL EXAMINATION

 Patient was conscious, and un cooperative patient is moderately nourished with truncal obesity with muscle wasting. Patient is unable to walk as there is swelling in his joints. And weakness in general

- Anemia present

- pallor present

- dyspnea present

- No clubbing

- No cynosis

- No generalized lymphadenopathy

Bilateral pedal edema present 

VITALS

Temperature - afebrile

Pulse rate- 98 /min

Respiratory rate-22/min

Blood pressure-140/90mm Hg

SpO2 at room air- 98%

GRBS- 140 mg%

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard

RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

Truncal obesity

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

PROVISIONAL DIAGNOSIS

Chronic kidney disease

INVESTIGATION

 Complete urine examination

 Complete blood picture

Serum creatinine

 Blood urea

Serum electrolyte 

Ultrasound Report 

 FINAL DIAGNOSIS

Chronic kidney failure on MHD

TREATMENT

Tab lasix - 40 mg BD

Nicardia- 20mg OD

Nodosis- 500mg BD

Shecal - 500mg OD