A 50 year old male patient with complaints of fever since 3 days accompanied by vomiting and grade IV SOB since 1 day with later development of renal failure - GM CASE 11
5th June 2023
CASE STUDY 11
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
- Fever since past 3 days accompanied by nausea, vomiting and grade IV SOB since 1 day.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months ago until he developed sudden onset of shortness of breath, chest pain and palpitations even at rest. He also complained presence of tingling sensation and tremors. He was diagnosed with CAD with stable angina and CKD and Hypertension. Patient is on dialysis treatment which is done once in 2 days. He was given 400mL of saline (0.95% NaCl) and excreted 50mL in urine on 5th June. He was again given 900mL saline solution out of which he excreted 100mL of urine on 6th June.
h/o nausea present
h/o vomiting present
h/o fever present
h/o burning micturition occasionally and reduced urine output
h/o diarrhea present
no h/o constipation
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o Typhood 15 years ago which was cured by medication.
h/o CAD with left ventricular dysfunction since 2 months.
h/o HTN since 2 months.
No K/C/O DM, Epilepsy and TB.
PERSONAL HISTORY:
Married since 1995.
Painter by occupation.
Is on a mixed diet.
Reduced appetite.
Disturbed sleep.
Regular Bowel movements.
Has no known allergies.
Consumes alcohol everyday since the time of marriage.
FAMILY HISTORY:
Has N/K/C/O Diabetes Mellitus, No HTN, 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 98.8°F
Pulse: 100 beats per minute
Respiratory rate: —44 cycles per minute
Blood pressure: 110/80 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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