GM CASE 7

GM CASE 7
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 portfolio
                    CASE HISTORY 
Patient Details 
A 55 Years old male ,Occupation-Agriculture,Resident of Nalgonda presented with 
Cheif complaints 
Patient complains of pedal oedema Grade 3 since 1 week and difficulty in breathing since 10 days.
History of present illness 
Patient was apparently asymptomatic 10 days ago then he developed Shortness of breath Grade 2 not associated with wheeze,  No aggrevating and relieving factors and Pedal oedema upto knee
Undergoing Dialysis.
History of past illness 
Hypertension since 8 years
CKD since 8 years
Diabetes mellitus-Absent 
Asthma-Absent 
Epilepsy-absent 
CAD-Absent
CVA-Absent
Undergone fistula surgery 9 months back
Personal History 
Diet-Mixed 
Appetite-Decreased 
Sleep-Adequate 
Bowel&Bladder-Regular
Micturition-Decreased
No known allergies 
Addiction-Smoking since 30 years
Family History 
No similar complaints
General examination 
Patient is conscious and Cooperative 
Pallor-present 
Icterus-Absent 
Clubbing-Absent 
Cyanosis-Absent 
Lymphadenopathy-Absent 
Edeoma-Present 
Vitals 
Temperature-96.6 F
Blood pressure-140/80
SPO2-97%
Respiratory rate-22/min
Systemic examination :
Respiratory System
*UPPER RESPIRATORY TRACT 
Oral Cavity-Normal
Dental caries-Not present
Staining-Present
No sinus tenderness
No deviation of nasal septum 
No Gingival Hyperplasia
*LOWER RESPIRATORY TRACT 
Inspection 
Chest appears symmetrical 
Trachea appears in midline
Drooping of shoulders-Absent
Supraclavicular Hollowing-Present
Infraclavicular Fullness-Absent
Harrison sulcus-Absent 
No pectus craniatum
Medial Border of scapula prominence-Present
Sinuses,Scars-Absent 
Movement of Respiration-Anteroposterior
Palpation
All inspectory findings are conformed
Trachea-Central
Intercoastal widening -Absent
Kyphoscoliosis-Absent
Dilated veins-Absent
Apical impulse-Absent
Chest movement-Anterioposterior
Percussion 
Right/left
*Clavicular space
*Supraclavicular
*Infraclavicular
 *Mammary
*Axillary
*InfraAxillary
*Suprascapular
*Infrascapular
*Upper/mid/lower interscapular
Dullness is elicited on 4th and 5th ribs on left side
Auscultation
Heart sounds-Normal
Added sounds-crackle sounds
Q/A
What are the reasons for decreased urine output?
What are the other systems which are affected because of oedema?




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