General medicine case-4

March 5 2023,
March 6 2023,

Case-4
March 6 2023,

Hi,I am Y.Ashwitha 3rd sem dental student.This is an elog book to discuss our patient health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:A 70 years old male came with a complaint of kidney failure and diabetes.

CHIEF COMPLAINT:
Patient had generalized swelling and shortness of breath form one week.

HISTORY OF PRESENT ILLNESS:
The patient was apparently Asymptomatic 1 year back,he had developed swelling of both lower limbs for which he went to asian institute of nephrology and diagnosed as chronic kidney failure and by put on medication he developed a swelling after 3 months and was taken to tha hospital and advised for heamodialysis ,raised creatinine levels are observed,Total 5 heamodialysis are done till now,Patient undergone regular peritoneal dialysis was done yesterday morning,since one week he had a shortness of breath whick was initially grade 3 and progressed to grade 4 and generalized oedema.

HISTORY OF PAST ILLNESS:
Diabetes mellitus: 10 years back
Hypertension:10 years back
IHD(ischemic heart disease):10 years back.
3 heamodialysis are done.

PERSONAL HISTORY:
No additions like alcohol and smoking,
Micturation abnormal,
Irregular bowel,
Loss of appetite.

FAMILY HISTORY:
No diabetis,
No hypertension,
No thyroid,
No cancer,
No asthma,
No tuberculosis,
No hear diseases.

GENERAL EXAMINATION:
No palor,
No icterus,
No cyanosis,
No clubbing of fingers,
No lymphadenopathy,
Presence of oedema,
No malnutrition.


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