A 43 year old man presented with shortness of breath

Hi, I am s princy rose , 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

August 27,2022
Case scenario.......


CASE SHEET:

Chief complaints:

A 43 old man presented with shortness of breath, orthopnea, PND and decreased output since one month 



HISTORY OF PRESENT ILLNESS:

Apparently asymptomatic one month ago and developed SOB , orthopnea and decreased urine output 









ASSOCIATED DISEASES:

Diabetes mellitus, hypertension 



PAST HISTORY:
Post CPR status revived 
K/c/o diabetes mellitus since 10 years
K/c/o HTN since 3 years

PERSONAL HISTORY:
 Appetite normal , mixed diet ,bowels regular, mituration normal , no known allergens, no addictions



FAMILY HISTORY:
No prominent history 


DRUG HISTORY:
Diabetes mellitus 
Hypertension 
CAD


GENERAL EXAMINATION:

>Pallor : Present

>Icterus : Not seen

>Cyanosis : Not seen

>Clubbing : Not seen

>Lymphadenopathy : Not seen


>Edema : B/L Pedal edema seen


VITALS:
Temperature: 98.6

Pulse: 88 beats per minute

Respiratory rate: 14 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 98

SYSTEMIC EXAMINATION:

Cardiovascular system
No thrills
No murumurs
Cardiac sounds: S1, S2 present 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid 
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

INVESTIGATIONS:
Biochemical investigations:
   

PROVISIONAL DIAGNOSIS:
CKD on MHD

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