GM CASE 6
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K.meghana 39 , k.Sai likhitha 37
Date of admission:18/09/2021
39 years old male who doesn't have any proper occupation came with the chief complaints of abdominal discomfort and SOB since 3days.
History of present illness:
Patient has similar complaints since 5 years .
Before diagonosing he had fever and loss of appetite since 1mon and also with cough, cold and throat infection along with back pain and he visited local hospital where they identified is creatinine high and let to kidney failure.
Before 3years he visited our hospital and he is undergoing dialysis since 3years weekly once.
Past history:
he had no similar complaints in the past.
he has hypertension since 2years
No h/o diabetes
No h/o epilepsy
No h/o TB
No h/o asthma
No history of any previous surgery in the past.
Personal history:
Appetite:normal
Diet:mixed
Adequate:sleep
Bowel and bladder movements :normal
Occasionally alcohol since 20 years. Cigarette 2 per day.
Family history:
No similar complaints in the family.
Drug history:
No allergy to known drugs.
General examination:
Patient is conscious,coherent, cooperative.
Pallor is present
No cyanosis
No lymphadenopathy
No clubbing
No icterus
No edema
No tremors
Vitals:
Temp:afebrile
Pulse rate:82/min
RR:18/min
Bp:130/90
Systemic examination:-
Cvs:
S1 and s2 are heard .
Respiratory system
No dysponea
Position of trachea central .
Abdomen:
Shape distended and obese
Non tender
CNS
Patient is conscious
Speech is normal
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