GM Case-4

GM case-4
Case scenario..
 Hi,I am K.Sathpriya,3rd BDS student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning.
                    Case History 
CHIEF COMPLAINT-
Shortness of Breath since 1 day
Decreased passage of urine since 1 day
Abdominal distension since 1 day
Pedal edema since 1 day
Facial puffiness since 1 day
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 1 day ago,then he developed shortness of breath since yesterday morning,it was sudden onset and aggrevates on walking,on supine position and decreases when he sleeps.
Abdominal distension-since yesterday,gradually progressive.
He didn't passed urine yesterday morning to evening.
Pedal edema since 1 day.
Patient had purulent secretions from area just below the scrotum and fever 4 days ago,then he called RMP and took Amoxicillin, paracetamol for 3 days,then fever and pus secretions are decreased.
But after 2 days patient developed edema in both upper and lower limbs and SOB, abdominal distension and decreased urine output since yesterday morning.
HISTORY OF PAST ILLNESSES-
Patient had similar history of SOB 6 months ago.For that he went to hospital in Devarakonda.There doctor has confirmed that there was accumulation of water in the chest region and prescribed medication,then it was cured after taking medication for 1 month.
History of epilepsy 15 years ago and not on regular medication.
Patient fell from the bridge 10 years ago and got spinal injury and spinal surgery was done.After 3 years,he had thrown pick in the right feet,the infection spreaded in the leg and amputation was done.
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet:Mixed
Apetite-Decreased since 4 days
Addictions: Stopped alcohol 1 year ago
No other addictions
No known allergies
GENERAL EXAMINATION
Patient was concious, coherent, cooperative 
Icterus-No
Clubbing-No
Cyanosis-No
Lymphadenopathy-No
Pedal edema-present.
Respiratory system examination 
INSPECTION:
•Chest is bilaterally symmetrical
Trachea – midline in position.0
Apical Impulse is not appreciated 
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
•Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both side.
PERCUSSION:
The following areas were percussed on either sides- 
Supraclavicular-resonant
Infraclavicular- resonant
Mammary- resonant
Axillary- resonant
Infraaxillary- resonant
Suprascapular- resonant 
Infrascapular- resonant 
 interscapular - resonant.
AUSCULTATION:
•Normal vesicular breath sounds heard.
• crepts present at right basal region 

Abdominal examination 
Distended
Abdominal rigidity present.
Tenderness present in epigastric region.
No fluid  thrill
No shifting  dullness 

CVS examination 
S1,S2 heard, no murmurs 
PROVISIONAL DIAGNOSIS:
Anasarca,chronic kidney failure 



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