Case 14 - A 43 year old man who is k/c/o CKD with history of CVA

A 43 year old man who is k/c/o CKD with history of CVA

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 43 year old man from Suryapet came to OPD for hemodialysis.

History of Presenting Illness
- patient was apparently asymptomatic 2 years ago when he developed weakness in left upper and lower limb and was diagnosed with Hypertension and a clot in the brain
- h/o SOB on exertion since 10 days 
- h/o nausea and vomiting 2 months ago, 2 episodes per day for 3 days, non-projectile and non-bilious, subsided on medication 
- h/o loose stools 2 months ago before and after a session of hemodialysis, 10 episodes in one day, watery, foul smelling and without any trace of blood, subsided on medication 
- h/o itching 2 months ago which subsided after 1 week of medication 
- no h/o cough, fever, headache, blurring of vision, chest pain, burning micturition and reduced urine output. 

Past History
- k/c/o of Hypertension since 2 years on irregular medication 
- h/o CVA
- n/k/c/o DM, tuberculosis, CAD, epilepsy, asthma and thyroid disorders 
- underwent 14 sessions of hemodialysis
- no h/o surgery 
- no h/o blood transfusions.

Personal History
- married
- manual labourer by occupation, stopped working since 2 years ago 
- mixed diet
- appetite normal 
- adequate sleep 
- regular bowel movements
- normal micturition  
- no known allergies
- chronic alcoholic since 20 years, stopped since 3 months
- chronic smoker since 25 years, 2pacs/day, stopped since 3 months 

Family History
- Not significant

Drug History

General Examination
- patient was conscious, coherent and cooperative 
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no pedal edema 
- no malnutrition 
- no dehydration 


Vitals
09/06/23
- BP: 140/90 mm Hg
- Pulse rate: 78 bpm
- Respiratory rate: 18 cpm
- Temperature: afebrile 
- SPO2: 98% at RA
- GRBS: mg/dL


Systemic Examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
- no adventitious sounds heard

Abdomen
- shape: scaphoid 
- no scars, striae, engorged veins
- no tenderness
- bowel sounds heard
- no bruits, rubs
- no shifting of dullness
- no fluid thrill
- no palpable mass
- hernia orifices: normal 
- liver: not palpable 
- spleen : not palpable

Central Nervous System


Investigations

Treatment 

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