CASE HISTORY
1 November , 2021
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A 51 yrs old male patient presented to the opd with chief complaints of swelling of the legs, shortness of breath, weakness , vomiting and fever.
HISTORY OF PRESENT ILLNESS:
Patient is agriculturer by occupation. Patient wakes up at 6 am in the morning. Between 6 to 12 patient supplies toddy to the people. At 11 patient comes back to home brushes his teeth and consume some amount of toddy. Around 11:30 he takes food and take rest till 2 pm. Between 2 to 4 he completes his routine agriculture work. At 4 in the evening till 6 he again supplies toddy to the people. At 8 he comes back home and consumes toddy .Around 9 he completes his dinner and goes for sleep.
Patient was apparently asymptomatic 2 years back. One day when patient was on his routine toddy work..while climbing the tree sensed severe pain around the ankle.
Patient consulted nearby hospital , he was given pain killers. Pain subsided when patient used the pain killer.The patient continued taking painkiller for 1 year.
Following this patient developed high fever, vomitings, swelling all over the body. Patient visited the nearby hospital and was told that kidneys got damaged and was suggested to visit Hyderabad hospital for medication.
Following this patient visited Hyderabad hospital. He was on medication for 6 months. Then the patient stopped using medication for a month..and consumed alcohol on the occasion of festival.
A week after patient developed weakness, vomitings , fever, shortness of breath, swelling over the legs...again visited the hospital in Hyderabad.
Patient was suggested for dialysis.. due to financial issues patient reported to our hospital on 31/10/21
PAST HISTORY;
No history of any surgeries in the past
No history of tuberculosis, asthma, CAD, epilepsy.
Patient is a known case of hypertension.
PERSONAL HISTORY:
Diet - mixed
Sleep- adequate
Appetite- reduced
Occasionally takes alcohol
No habit of smoking
Bowel movement- regular
FAMILY HISTORY:
No history of similar complaints in the family.
GENERAL EXAMINATION:
Patient is conscious , coherent and cooperative.
No cyanosis
No lymphadenopathy
No icterus
Pallor is seen
Edema is seen.
VITALS:
Temperature-98.6 degrees F
Pulse rate- 92 beats /min
BP- 140/90 mm of Hg
Respiratory rate- 24 /min
SYESTEMIC EXAMINATION:
CVS:
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM:
Dyspnea- yes
No wheeze
Postion of trachea- Central
Breath sounds - Vesicular
ABDOMEN:
No tenderness
No palpable mass
No bruit
No free fluid
CNS:
Level of consciousness- conscious
Speech - normal
No neck stiffness
INVESTIGATIONS:
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