Case history -8
October 18, 2021
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A 45 yrs old man presented to the opd with chief complaints of shortness of breath and swelling of the legs.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months then developed shortness of breath and swelling of legs
Patient was diagnosed as chronic renal failure and dialysis was initiated.
Patient is a known case of hypertension since 6 years.
Patient tested covid-19 postive 4 months back.
PAST HISTORY:
No history of any surgeries in the past.
No history of diabetes, asthma, CAD, epilepsy
Patient is a known case of hypertension.
FAMILY HISTORY:
No history of any surgeries in the family
No history of diabetes and hypertension.
PERSONAL HISTORY:
Appetite - normal
Diet - mixed
Sleep- adequate
Bowel and bladder movement- regular
No habit of smoking
GENERAL EXAMINATION:
Patient is conscious, coherent ,and cooperative
No pallor
No cyanosis
No lymphadenopathy
No icterus
No clubbing of fingers
VITALS:
Temperature- 98.4 degrees F
Pulse- 84 beats/min
BP- 140/100 mm of Hg
Respiratory rate- 24 /min
SYESTEMIC EXAMINATION:
CVS:
No thrills
S1S2 heard
RESPIRATORY SYSTEM-
No wheeze
Postion of trachea- Central
Breath sounds- Vesicular
ABDOMEN-
Shape- Scaphoid
No tenderness
No palpable mass
No brui heard
CNS:
Level of consciousness- Conscious
Speech- Normal
No neck stiffness
INVESTIGATIONS:
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