A case of Chronic renal failure

GM-4 


Hi ,i am K.Shreya3rd year  BDS student .
This is an online elog book to discuss our patient data after taking her concent this also reflects my patient centred online learning portfolio .

Case sheet:A 40year old male admitted in hospital with persistent cough 

Chief complaint : patient complains of cough with sputum (mucoid type , yellowish ,without blood stains)since 20 days and decreased appatite since 10 days .

History of present illness:patient was apparently asymptomatic 20days back then he developed cough with sputum (productive cough)which is continuous and gradually progressive 
He went to local hospital and routine tests was done and found problem related to kidneys and he is on medication and dialysis still now .He is on dialysis which is on alternate days 
He experienced edema after using the medication but later it is subsided .
Aggrevating factors-Lying down in supine position and during nights 
Relieving factors-Medication

History of past illness:
Hypertension since 20days 
On medication -NIFEDIPINE (20mg)
Asthma since 20days (BUDESONIDE NEBULISER SUSPENSION)
Not a known case of TB/epilepsy/Diabetes mellitus

Family history:No

Personal history:
Patient is conscious and cooperative .He is moderate in built and moderately nourished
Occupation:farmer
Diet.       :mixed
Appetite. :decreased
Sleep.      :normal
Bowel and bladder: normal
Addictions.     : Toddy (occasional since 20yrs)
Smoking         :no

General examination:
Palor :no
Icterus:no
Cyanosis:no
Clubbing :no
Lymphadenopathy:no
Edema :no

Investigations: Chest X-ray, CBP,serology ,ECG,LFT,RFT,CUE

Provisonal diagnosis:
Chronic renal failure

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