42M With SOB and loss of consciousness

Hello all this is G Jagadeesh,a fifth semester student.This E Log depicts the patient centered approach to learning.

This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

 A 42 year old male working as a rice farmer , hailing from Nalgonda presented to the OPD with shortness of breath , loss of consciousness 2 days ago

history of Present illness 

patient was apparently asymptomatic 15 years ago

15 years ago , he had complaints of polyuria , nocturia , polyphagia , polydispsia and dizziness , he went to a government hospital and he was diagnosed with DM 2 , he reported that he is taking the prescribed  medication regularly .

5 years ago he had dragging type of pain at the back of head , he went to a local hospital where he was diagnosed with HTN , pateint reports taking the prescribed medication regularly 

1 year ago he complained of  shortness of breath , pedal edema , weakness and dizziness after visiting a government hospital after a fainting spell , he had a creatinine level of 7 and was recommended to start dialysis 

the patient has been on dialysis for 1 year , 2 months ago he reported paroxysmal nocturnal dyspnoea 

2 days ago , during his routine dialysis , he had 3 episodes of vomiting and shortness of breath and was intubated 

history of past illness 

he is a known case of DM2 , HTN

he is n/k/c/o epilepsy , asthma , tuberculosis 

personal history

diet : mixed 

appetite : normal

occupation : rice farmer 

micturition : on a foleys catheter  

bowel movements : reduced 

addictions : reports intake of alcohol occasionally 

                       smoked cigarettes occasionally 

allergies : not known 

family history 

- elder brother and younger sister have DM 2

---------------------------------------------------------------------------

examination 

general examination 

pallor : present 

icterus : absent 

cyanosis : absent 

clubbing : absent 

lymphadenopathy : absent

pedal edema : present , pitting type pedal edema , reduces on rest and elevation





vitals :

pulse rate : 74bpm

rr : 22cpm

BP : 150/100 mmHg

systemic examination

CVS

-thrills : no

- cardiac sounds : S1 S2 heard

-cardiac murmurs : no

 Respiratory system 

position of trachea : central 

dyspnoea : present 

wheeze : no

PA 

normal 

CNS 

normal

on examination of nails 

he has onychomycosis 


JVP video 






INVESTIGATIONS 






provisional diagnosis 

chronic kidney disease secondary to Diabetic nephropathy 


Case update 1/07/2022

Today nephrology update


Icu bed 4


http://drkulkarnimd.blogspot.com/2022/06/42m-with-sudden-sob-and-pedal-edema.html


Day 1 : 

S - patient is off sedation & paralysis and moving all 4 Limbs and responding to commands (1 step )


O - bp 140/90 

Pr 82 cpm

RR 22 cpm

Spo2 97%

Cvs S1 S2 heard

RS - BAE PRESENT

E4VtM6









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