A 66 year old male with Chronic Renal Failure
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
05/08/2022
Blog by Janhavi Virani
Roll no 58
A 66 year old male who is a resident of Suryapet and a businessman by occupation came to opd four days back with chief complaints of
1. Pedal Edema since 3 months
2. Shortness of breath since 3 months
HOPI -
Patient was apparently asymptomatic 12 years back .
He was having complaints of vomitings and chest pain and was diagnosed with Ischaemic Heart disease and went through bypass surgery (CABG) .
The same time he was diagnosed with DM and Hypertension.
3 months back was having pedal Edema which is pitting type and extends till knees . shortness of breath on walking a long distance for which he went to hospital and was diagnosed with kidney disease.
He came here 4 days back for dialysis. He had 2 rounds of dialysis till now .
DAILY ROUTINE-
PAST HISTORY-
A known case of Diabetes Mellitus and Hypertension since 12 years
No history of Tb , Epilepsy , Asthma , Thyroid abnormalities.
He has history of CAD
SURGICAL HISTORY- went through CABG 12 years back .
FAMILY HISTORY- no significant family history
DRUG HISTORY- he has no drug allergy and is on medication for DM and HTN .
PERSONAL HISTORY-
Diet - stopped eating non veg since 3 months
Appetite- normal
Sleep- not adequate
B&B- burning micturition and increased frequency
Addictions- none
GENERAL EXAMINATION-
patient is conscious, coherent and cooperative
Moderately built and nourished
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Generalised Edema - pedal Edema present since 3 months and also periorbital Edema in right eye . He had it in left eye as well which reduced after going through cataract surgery in left eye .
VITAL -
Temperature- a febrile
PR - 65bpm
RR - 16 cpm
BP - 130/70mm of hg
Postural tremors are present-
SYSTEMIC EXAMINATION-
Cardiovascular system
JVP - not raised
Visible pulsations: absent
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent
S1, S2 - heart sounds heard
Pericardial rub - absent
Respiratory system:
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Scar - present ( CABG)
Chest movements : bilaterally symmetrically
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical
AUSCULTATION
BAE+, NVBS
Abdomen examination:
INSPECTION
Shape : normal
Scar : Present
Umbilicus:normal
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal
PALPATION
Tenderness: presented in lower right quadrant ( right flank pain radiating to loin )
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard
CNS :
Higher mental functions intact
No focal neurological deficit’s present
PROVISIONAL DIAGNOSIS-
Chronic Renal Failure associated with diabetes and hypertension since 12 years .
INVESTIGATIONS-
TREATMENT-
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