Gm blog -11/4/23

A male patient aged 26years who is a resident of Akkenpally, carpenter by occupation, came with 
CHIEF COMPLAINTS OF:
              H/o shortness of breath since 5 days and swelling of limbs since 2weeks
H/o cough since 2weeks.
HISTORY OF PRESENT ILLNESS:
           Patient was apparently asymptomatic 2weeks back and he developed swelling in lower limbs which is incidious in onset,gradually progressive to upper limbs and now entire body,not relieved on medication.
Patient complains of cough since 2weeks with sputum and also c/o sob since 5 days which is incidious in onset, gradually progressive (grade 2-3) aggravated on excertion and not relieved on medication.
No h/o fever, palpitations, sweating,snoring, vomitings and burning stools.
PAST HISTORY:
       K/c/o diabetes since 5 months and on tab.Metformin and a k/c/o hypertension since 7years and on tab.Nicardia.
      No h/o asthma, thyroid disorders, epilepsy, hypertension, diabetes, CAD
SURGICAL HISTORY:
         No past surgical history.
FAMILY HISTORY:
            Not significant
TREATMENT HISTORY:  
            Tab.Metformin and tab.Nicardia
PERSONAL HISTORY:
          Appetite:normal
Diet : mixed

Sleep: Adequate

Bowel and bladder movements : regular

Addictions : none

He has no known allergies. 

GENERAL EXAMINATION:

           Patient is conscious , coherent , cooperative 

Patient is moderately built and nourished

VITALS:

BP: 130/90 mm hg

PR: 86 bpm

RR: 18cpm

temperature: 98.2*F .febrile

SPO2: 98%
PHYSICAL EXAMINATION:

       Pallor:present

       Icterus: absent

cyanosis: absent

clubbing : absent

lymphadenopathy:absent

pedal edema: present
SYSTEMIC EXAMINATION:

CVS:

S1 and S2 are heard

No thrills

No murmurs

Respiratory system:

INSPECTION: 

Tracheal position is central
Bilaterally symmetrical chest 
Elliptical in shape
Palpation:

All inspectory findings are confirmed by palpation


PERCUSSION:

Resonant on percussion. 

AUSCULTATION:

Breath sounds are normal. 

PER ABDOMEN

Shape : scaphoid

Tenderness : absent

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

Bowel sounds : absent 

CNS:

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves : intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal. 

INVESTIGATIONS:


PROVISIONAL DIAGNOSIS:
        CHRONIC RENAL FAILURE.


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