GM case 5

GM case 5
August 1,2023



Case scenario

My self k.priyanka 3rd bds student .This is an online e blog to discuss our patient health data shared after taking her guardian sign  informed consent.here we discuss our individual patient problem through series of inputs from available global online community with aim to solve patient problem.

Chief compliant
A 60 years female patient came to OPD  with chief compliant of back pain, swelling of legs ,from 6 months.

History of present illness
Patient was apparently asymptomatic 6months back and than she developed lower back pain which is progressing down wards to upwards which is of pricking type of pain.swelling of legs from 6 months non pitting and increases while walking.she has intermittent fever ,knee pains .shortness of breath from 6 months which is grade 4.

History of past illness
Patient has no similar complaints in past.
History of chest pain which is of burning type.
Burning mixturation.
Hypertensive from 6 months
No diabetic,cad, epilepsy,tb,asthama.
Dialysis from 6 months

Personal history
Diet mixed
Apatite decreased
Sleep inadequate
Bowel and bladder irregular 
No allergies
No addiction


Family history
No similar history in family.

General examination
Conscious cohorent cooperative
Well built and moderately nourished.

Pallor pale
Icterus no
Cyanosis no
Clubbing no
Lymphedenopathy no
Edema present ,non pitting

Vitals
Temp afebrile
Pulse rate 65bpm
Resp rate 24 cycles per min
Bp 110/90


Systemic examination

Respiratory system

Inspection
Upper respiratory tract
Oral hygiene good
No caries
No haltosis
No nasal septum deviation
No sinus tenderness
No tonsills


Lower respiratory tract

Chestis symmetrical
No drooping of shoulders
Trachea midline
No suprascapular and infrascapular hallowing
No pectus carinatum,pectus excavam,kphyoscoliosis

Palpation
Inspiratory findings are confirmed
Superficial
Rise in temperature
Trachea midline 
No drooping of shoulders
Transverse 50
Anterio posterior 30
Thoracic circumference 80
Semi thoracic 40

Percussion

Clavicular supra and infra
Mamillary 
Axillary infra and supra
Suprascapular and infrascapular
All resonate sounds heared

Auscultation

Vesicular breath sounds 16 / min.

Provisional diagnosis
Chronic kidney disease.

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