A 70 year old patient with recurrent fever, emesis, chronic joint pain and renal failure 3 years ago - GM CASE 17
20th June 2023
CASE STUDY 17
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
- 2-3 episodes of emesis over one night 15 days back accompanied by nausea.
- recurrent fever since 15 days
- pedal edema with edema of the upper limbs since 15 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 25 years ago until until he gradually developed joint pain in both the lower limbs majorly the knees. He consumed medications for the same which helped him relieve the pain. 3 years back, he got a fracture of the lower right leg and simultaneously SOB on exhertion for which he was taken to Nalgonda hospital. There he was diagnosed with chronic kidney disease for which he was prescribed Sodium Bicarbonate and other pain killers for the above mentioned fracture. At the same time he also developed back pain for which he did not take any particular medication. 1 year ago he again got a fracture on the same limb gor which he was treated and given medication for the pain. Until 2 weeks back, he was apparently doing well when he developed 2-3 episodes of vomiting overnight which was projectile, yellowish, bilious, contained no food contents and copious in amount with no traces of blood. This was accompanied by nausea. On 14th June he had his 1st episode of dialysis in our hospital and on 21st (i.e today) is his 4th appointment.
-no h/o burning micturition
-reduced urine output
-h/o itching and rash on both Upper and Lower limbs along with face for which he did not take any medication and healed spontaneously.
-h/o reccurent fever ever since the vomiting episodes began. The fever was not high grade and reduced on medication.
-h/o cough with sputum since 15 days for which he consumed no medication.
-h/o constipation 15 days ago with 3 episodes/week which was watery.
-no h/o diarrhea
-no h/o headache, blurring of vision.
ASSOCIATED DISEASES:
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PAST HISTORY:
No K/C/O HTN, DM, Epilepsy, CAD.
h/o of having Tuberculosis 5 years back for which he was treated.
PERSONAL HISTORY:
Married.
Farmer by occupation.
On a vegetarian diet since 3 years.
Adequate sleep.
Reduced appetite.
Normal Bowel movements.
Has no known allergies.
Has no known addictions.
FAMILY HISTORY:
Has N/K/C/O Diabetes Mellitus, No HTN, No Strokes. No CAD, TB, Asthma or Epilepsy.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No Icterus
-No cyanosis
-No lymphadenopathy
-pedal edema present with edema of both the hands since 15 days.
-No clubbing of fingers
VITALS:
Temperature: Febrile - 99.9°F
Pulse: 80 beats per minute
Respiratory rate: —16 cycles per minute
Blood pressure: 110/70 mm of Hg
SPO²: 98%
GRBS: 173mg%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
-Shape : Scaphoid
-No Tenderness present
-No palpable mass
-Non palpable spleen
-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:
ULTRASOUND REPORT:
GRAPHIC SHEET :
PROVISIONAL DIAGNOSIS:
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