GM case

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including histoty, clinical findings, investigations and come up with a diagnosis and treatment plan.




Case :

A 70year old male who is resident of chinnatummaralagudem came to OPD with

Chief complaints :
Fever since 20days.
Nausea and vomiting since 10days.
SOB since 10days.
   ,,    
 H    isto ry of present illness :
0Patient was apparently asymptomatic ppp⁰s back then he developed fever of high grade which is of intermittent type, not associated with chills and rigor and relived on taking medication. 
No history of generalized weakness and giddiness.
He had nausea and vomiting which is of non bilious, non projectile, non blood stained containg food particles not associated with pain. 
SOB (grade 2) is insidious onset, gradually progressive not associated with chest pain and relieved on taking rest.

Past history :
No similar complaints in the past.
K/c/o DM since 4years and on regular medication.
N/k/c/o HTN, TB, asthma, epilepsy, CAD.

Personal history :
Diet : mixed
Appetite : decreased
Sleep : adequate
Bowel and bladder movements : regular but burning micturition is present.
Addictions : occasional alcohol drinker but stopped consuming 4yrs back.

Family history :
Not significant.


General Examination 

Patient was conscious, coherent, cooperative. 
Moderately built and nourished.
Pallor : yes
Icterus : no
Cyanosis : no
Clubbing : no
Lymphadenopathy : no
Pedal oedema : yes (grade 1).

Vitals 
BP : 120/80mmHg
PR : 70bpm
RR : 16cpm
Temperature : afebrile


Systemic Examination 
CVS : 
S1, S2 heard.
No murmurs.

Respiratory system:
Inspection :
Shape of the chest is elliptical.
No scars and sinuses are seen.
No nodules and engorged veins are seen.
Trachea is seen centrally.
Movements are bilaterally symmetrical.

Palpation :
Trail's sign : trachea is placed centrally.
Apex beat is in Left 5th intercoastal space 1 - 2cm medial to the mid clavicular line.
Symmetrical expansion of chest.
No tenderness.
Vocal fremitus : resonant.

Percussion :
On percussion resonating sound heard.
Tidal percussion : resonant sound.

Auscultation :
Normal vesicular breath sounds are heard.


Per abdomen :
Inspection : 
Abdomen is scaphoid.
No scars are seen.
Umbilicus : inverted.
Gentle rise in abdominal wall in inspiration and a fall during expiration. 
No visible pulsations.
No visible gastric peristalsis.

Palpation :
No hepatomegaly.
No spleenomegaly.
No tenderness.

Percussion :
No shifting dullness and fluid thrill are seen.

Auscultation :
Normal bowel sounds are heard.


CNS :
Patient is conscious.
Cranial nerves are intact.
Sensory system is normal.
Motor system is normal.


Provisional diagnosis :
Chronic kidney disease.

Clinical Images :

Investigations :
LFT :
Blood sugar levels :

Hemogram :
Serum iron :

Blood Urea :

Serum electrolytes and serum ionized calcium:

Serum Creatinine :

Anti HCV antibodies :

Erythrocyte Sedimentation Rate :

HBsAg :

HIV Test :

Hemogram :

ECG :
Final diagnosis :
Chronic kidney disease.

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