50 year old male with complaints of shortness of breath and vomiting

Hi, I am Gaddam shreya of 3rd semester .This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

A 50year old male, labourer by occupation came to OPD with chief complaints of shortness of breath since 6days and vomiting since 4 days. 

HISTORY OF PRESENT ILLNESS-
Patient was asymptomatic 1 year back.
Then he Diagnosed with chronic kidney disease he is on conservative treatment.
SOB is insidious in onset, not present during rest and is more prevalent during night (PND). SOB is generally experienced after walking a short distance.The patient also complained that the breathlessness is increased by lying down suggesting orthopnea.
Vomiting is present since 6 days immediately after intake of food
No history of fever

PAST HISTORY 
The patient was known to be hypertensive since 1 year for which he is on regular medication
Also 1 year ago patient diagnosed with CKD

PERSONAL HISTORY 
DIET: Mixed
APPETITE : Normal
BOWEL AND BLADDER: Regular
SLEEP: Adequate
ALLERGIC HISTORY: No known allergies
NO ADDICTION 

FAMILY HISTORY
No relevant family history

GENERAL EXAMINATION
The patient is conscious, coherent and Co-operative
The patient is moderately build and moderately nourished.
No pallor
No cyanosis
No clubbing of fingers
No lymphadenopathy
No icterus
No Oedema of feet

VITAL SIGNS-
TEMPERATURE:98.6 degree F
PULSE RATE:102bpm
RESPIRATORY RATE:35/ min
BLOOD PRESSURE:180/100 mm Hg
SpO2:98%
GRBS:138 mg/dL


SYSTEMIC EXAMINATION
CVS:
S1 S2 Heard,
no murmurs 

RESPIRATORY SYSTEM:
No scars are seen on inspection
Shape of the chest:
Tracheal position:Centre
Bilateral Chest Movement 
Tracheal position is confirmed by palpitation
Dyspnea present 
Wheeze absent 
Breath sounds are Vesicular

ABDOMEN-
Abdomen is scaphoid
No tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 
Conscious 
Speech- normal
Signs of meningeal irritation - 
no neck stiffness
no kerming's sign
Cranial system - intact 
Motor system - intact 
Sensory system - intact 
 Cerebeilar signs
    Finger nose- in coordination
    Knee heel - in coordination

Investigation -
Ultrasound, hemogram , serum iron, ECG,RFT, LFT, blood sugar random


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