Case 10 A 51 year old man with CAD and CKD

A 51 year old man with CAD and CKD


Hi, I am R. Ramya Keerthana, 5th semester medical student. This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.

Case Scenario 
A 51 year old man from Suryapet came to the casualty on 4th of June with chief complaints of :
- fever since 3 days 
- SOB since 1 day.

HISTORY OF PRESENTING ILLNESS
- patient was apparently asymptomatic 3 months ago when he developed chest pain, palpitations and SOB of Grade 4 
- he also complained of tingling sensation and tremors in hands
- h/o vomiting present 
- h/o fever present 
- h/o burning micturition and reduced urine output 
- h/o diarrhea present 
- no h/o constipation, rashes.

PAST HISTORY
- h/o Typhoid 15 years ago
- k/c/o CAD with stable angina and left ventricular dysfunction since 2 months
- k/c/o HTN since 2 months
- k/c/o CKD since 2 months and had undergone 5 sessions of hemodialysis 
- N/ K/C/O diabetes mellitus, epilepsy, tuberculosis and thyroid disorder.

PERSONAL HISTORY
- married 
- painter by occupation 
- mixed diet
- reduced appetite
- inadequate sleep
- regular bowels
- burning micturition with reduced urine output 
- no known allergies
- chronic alcohol since 26 years.

FAMILY HISTORY
- h/o HTN and CKD
- no h/o  diabetes mellitus, strokes, CAD, tuberculosis, asthma, epilepsy, thyroid disorders or cancers.

DRUG HISTORY

GENERAL EXAMINATION
- Palor: 
- Icterus:
- Cyanosis:
- Clubbing of fingers:
- Lymphadenopathy:
- Pedal edema:

VITALS
04/06/23
- Temperature: 98.8°F
- Pulse: 110 bpm
- Respiratory rate: 24 cpm
- Blood pressure: 140/80 mm of Hg
- SPO2: 94% at RA
- GRBS: 120mg/dl

05/06/23
- Temperature: 99.7°F
- Pulse: 114 bpm
- Respiratory rate: 42 cpm
- Blood pressure: 130/70 mm of Hg
- SPO2: 99% at RA
- GRBS: 109 mg/dl

06/06/23
- Temperature: 104°F
- Pulse: 112 bpm
- Respiratory rate: 42 cpm
- Blood pressure: 100/70 mm of Hg
- SPO2: 97% at RA
- GRBS: 147 mg/dl

Fluid Intake and Urine Output
05/06/23
Total Intake: 400 ml
Total Output: 50 ml

06/06/23
Total Intake: 400 ml
Total Output: 100 ml

SYSTEMIC EXAMINATION
Cardiovascular system
-No thrills
-No murumurs
-Cardiac sounds: S1, S2 present 

Respiratory system
-No dyspnea
-No wheezing
-Breath sounds heard: vesicular
-Tracheal position: Central 

Abdomen
-Shape : Obese
-No tenderness
-No palpable mass
-Hernia orifices : normal
-Liver: non palpable
-Spleen: non palpable 
-No free fluid
-No bruits
-Bowel sounds: heard

Central Nervous System



INVESTIGATIONS

Treatment



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