Case history-06

October 29, 2021

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

A 75 year old male who is farmer by occupation came to the OPD with the chief complaints of pedal edema and facial puffiness since 3days

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

He used to get up at 6 in the morning, used to have tea then breakfast at 8 (rice) then used to go for farming, he used to have lunch at 2 which is rice again. He used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that.

The Patient was apparently asymptomatic 3 months back then he had fever first which didn't subside even after 4 days. He then experienced shortness of breath while still having fever.

He went to a local doctor, symptoms did not subside and then came to our OPD where he was diagnosed with CKD and hypertension

He used to have acidity from past 3 years occasionally for which he used to have antacids.

He also had a slight pain in the lower part of the abdomen

From the past five days, whatever he is eating is being vomited out which is non bilious, has no prior nauseous feeling, no vertigo, no blood, the content is which he eats at that time only, he is vomiting the undigested food. He is not even passing stools.

HISTORY OF PAST ILLNESS:

The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma

PERSONAL HISTORY:

-The patient has lost appetite

-abnormal micturation

-no sleep disturbances

FAMILY HISTORY:

There are no similar complaints in the family members

TREATMENT HISTORY:

The patient is not a known case of drug allergy

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining