SHRUTHI ARUKONDA 02



 GENERAL MEDICINE. 


18 June ,2022.  

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


             CASE REPORT

A 57 year old male with chief complaints of pedal oedema, shortness of breath , and decreased urine output.  

CHEIF COMPLAINTS: 
Pedal Oedema 
Shortness of breath since 10 days.  
Decreased urinary output since 1 week.  


HISTORY OF PRESENT ILLNESS: 



HISTORY OF PAST ILLNESS: 
 Hypertension: since 10 years 
N/k/c/o TB, epilepsy, DM. 

TREATMENT HISTORY: 
Nothing significant 

PERSONAL HISTORY: 
Appetite : decreased 
Vegetarian since one year 
Sleep: 
Alcohol: stopped since one year 
Smoke : stopped bidi since one year 

FAMILY HISTORY : 
Nothing significant 

PHYSICAL EXAMINATION: 

GENERAL EXAMINATION: 
Pallor : seen 
Oedema of feet : seen (pitting). 
No signs of icterus, cyanosis, clubbing of fingers, lymphadenopathy.  

VITALS: 
Temperature : 98.6
Pulse rate : 98
Respiration rate : 
BP: 140/90
sPO2: 90%
GRBS: 98mg% 

SYSTEMIC EXAMINATION : 

CVS: 
Thrills : no 
Cardiac sounds: S1,S2 +
Cardiac murmurs : no 

RESPIRATORY SYSTEM : 
Dyspnoea : 
Wheeze : BAE +.   BASAL EMPTY + 
Position of trachea : central. 

ABDOMEN: 
Shape of abdomen : scaphoid 
Tenderness: not 
Palpable mass: no 
Hernial orifice:Normal 
Free fluid: no 
Bruits: no 
Liver: not palpable 
Spleen: not palpable 
Bowel sounds: yes 

CENTRAL NERVOUS SYSTEM: 
1. Level conscience: conscious 
2. Speech: normal 

INVESTIGATIONS: 

1. Blood grouping and RH type: 


2. CBP: 


3. USG: 


4.ABG: 



5. Blood sugar - random : 


6. LFT. 


7. RFT. 


8. SERUM IRON : 



9. HBsAg- rapid : 


10. CUE : 



11. HIV : 




12. ECG: 

16/06/22: 

18/06/22: 



PROVISIONAL DIAGNOSIS: 
CKD in MHD.  
Hypertension.  





















































































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