A 43 year old male patient with lower limb pedal edema and grade II SOB for maintenance dialysis - GM CASE - 15
10th June 2023
CASE STUDY 15
Hello, I am Saloni .S. Gangotri , a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- pedal edema since 20 days on lower limb.
- SOB grade II since 10 days.
-came for maintenance dialysis.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years ago until he developed sudden weakness in both upper and lower left limb during midnight. He was brought to OPD the ext morning and on investigation he was diagnosed with a brain clot for which he was given regular medication. However he did not consume the medication regularly. He was also diagnosed with hypertension through the scan and was prescribed medication which again he did not consume regularly. He has had 10 dialysis appointments until now since 9th may'23 with having twice per week.
h/o nausea present
h/o vomiting present. He had 2 episodes of vomiting per day 2-3 days ago after consumption of food which was non bilious, non projectile contained food contents with no traces of blood.
no h/o fever.
h/o burning micturition occasionally.
h/o diarrhea present before and after his first dialysis in the 2nd hospital he was taken to. Watery stools were present with 10 episodes/ day. It was relieved on medication.
no h/o constipation.
no h/o headache, blurring of vision, fever or cough.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o HTN since 2 years and is on irregular medication.
No K/C/O DM, Epilepsy and TB, Asthma, Thyroid disorders, CAD.
No surgical history.
No h/o blood transfusions.
PERSONAL HISTORY:
Married since 10 years.
Labourer by occupation. Quit working 2 years ago.
Was on a mixed diet but is now a vegetarian since 2 months.
Normal appetite.
Reduced sleep.
Regular Bowel movements.
Has no known allergies.
Consumed alcohol everyday since 20 years and smoked 2 packs of cigarettes since 25 years per day. Stopped since 2 months.
FAMILY HISTORY:
Has h/o uncle having DM and HTN.
Has N/K/C/O No Strokes, No cancers. No CAD, TB, Asthma or Epilepsy.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-No pedal edema
-No clubbing of fingers
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VITALS:
Temperature: Febrile - Afebrile
Pulse: 78 beats per minute
Respiratory rate: —18 cycles per minute
Blood pressure: 140/90 mm of Hg
SPO²: 98%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Tracheal position: Central
Abdomen:
Shape : Obese
No tenderness
No palpable mass
No palpable spleen
Hernia orifices : normal
Non palpable liver
No free fluid (ascites) present
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D-ECHO REPORT:
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ULTRASOUND REPORT:
GRAPHIC SHEET :
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PROVISIONAL DIAGNOSIS:
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