GM case -4
Date of admission : 9 /08/2021
A 60 year old male who is an agriculture worker came with cheif complaint of swelling of hands and leg , shortness of breath since 1year .
History of present illness:
Patient was asymptomatic 1year back before he developed swelling of legs and hand but he neglected it later so it become progressive with shortness of breath and decreased urine output.
Past history:
Decreased urine output 1year back
Hypertension since 3years.
No history of diabetes
No histoy of epilepsy
No history of tb
No history of any previous surgeries
Personal history:
Diet -mixed
Sleep-decreased
Appetite-decreased
Bladder-regular
Bowel: regular
No addictions.
Family history:
No similar complaints in the family are seen.
Drug history:
No allergy to known drugs.
General examination:
Patient is coherent,cooperative,conscious.
No pallor
No cyanosis
No lymphadenopathy
No malnutrition
No pedal edema
No clubbing of fingers.
Vitals:
Temp :98.4°f
Pulse rate: 110/min
Respiratory rate :18 cycles/min
Bp:130/90 mmhg
Systemic examination:-
Cvs:
S1 and s2 are heard.
Respiratory system:
Position of trachea is central
No dysponea
Abdomen:
No tenderness
Shape of abdomen is scaphoid.
No palapable mass
Provisional diagnosis:
Ckd on mhd
Investigation:
Serum creatinine:
Ultra sound report form :
Final diagnosis:
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