General medicine case-1
General Medicine Case History 1
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This is a case of 45 year male patient who is a farmer by occupation presented with chief compliant of swelling of lower limbs, difficulty in breathing since 1 1/2 year.
3 months back he was diagnosed covid positive
After which the earlier symptoms of pedal edema, shortness of breath, decreased urine output got exacerbated.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 mnths back.
Then he was diagnosed covid positive
Later he developed pedal edema which was gradual on onset and progressive in nature.
He had shortness of breath, decreased urine output, orthopnea and dyspnea.
No vomitings.
Presently he is on dialysis.
HISTORY OF PAST ILLNESS:
Known case of chronic kidney disease 1 and half year,known case of hypertension since 1 year & on tablet CILACAR 10 mg morning , 20 mg night
No h/o diabetes, asthma, TB, epilepsy.
No h/o of surgery.
PERSONAL HISTORY:
Diet -was mixed till 3 months back,
Appetite : normal
Bowel & Bladder movements: regular
Sleep :adequate
Addictions: Alcoholic but stopped 4months back, no smoking.
FAMILY HISTORY:-
no history of similar complaints in the family.
TREATMENT HISTORY:-
no history of drug allergies.
GENERAL EXAMINATION:-
patient was conscious,coherent and cooperative.
He has pedal edema( pitting type)which extended from feet to knee which was subsided after dialysis
He has pallor
no clubbing
No cyanosis,
No icterus,
No generalised lymphadenopathy
VITALS-
temperature - 98°F
Pulse - 94bpm
Respiratory rate - 22 cpm
Bp-140/90
SYSTEMIC EXAMINATION -
CVS-inspection
Chest wall is bilaterally symmetrical.
No precardial bulge
No visible pulsations, engorged veins, scars and sinuses
PALPATION
Jvp is normal
AUSCULTATION -
S1 ans s2 heard
PER ABDOMEN:-
abdomen is not tender and soft
CNS:-
patient is concious
Speech is present and normal.
RESPIRATORY SYSTEM:
Bilateral air entry is normal.(BAE)
Dyspnea is present.Normal vesicular breath sounds heard( NVBS)
PROVISIONAL DIAGNOSIS:- kidney disease.
FINAL DIAGNOSIS - Chronic Renal disease.
INVESTIGATION:
Serum creatinine 29/07/2021
Hemogram 29/07/2021
