GM case 3

Gm Case 3

Case scenario......

Hi, this is P. Bhavana of 3 rd BDS student. This is an online eblog book to discuss our patient's health data after taking his consent. This also reflects my patient centred online learning portfolio.

CASE SHEET:

A 65 year old who has shortness of breath and swollen feet 

Chief complaint:

Patient complains of shortness of breath and swollen feet.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 10yrsago.

Since 10 years patient complains of hypertension.

6years ago sudden bleeding of nose.

Then he visited a hospital and incidently came to know that he was diagnosed with kidney failure.

From then he is on medication.

1 month ago he was suffering from shortness of breath and swollen feet.

While he is walking for long, he feels more breathless than usual.

As a part of regular checkup the doctor suggested to go through dialysis.

The patient is on dialysis since a month.

Urine output is decreased since one month.

The patient has on and off fever since 7days.

He has continues cough.

Cough is releaved during dialysis.

PERSONAL HISTORY:

Before he diagnosed with kidney failure he used to wake up early in the morning and have his breakfast around 7.30AM. Then he goes on field work. He takes his lunch around 12:30pm. Hegoes back to his field work. At 10 Pm he goes to sleep.

When he diagnosed with kidney failure he was unable to work in the field.

He has irregular sleep since then. This is the difference we diagnosed.

Marital status: married

Occupation: agriculture

Diet: mixed

Sleep: irregular

Appitite: lost

Allergy: no

Family history: his mother diagnosed with hypertension

GENERAL EXAMINATION:

Pallor: no

Icterus:no

Cyanosis:no

Lymphadenopathy: no

Clubbing:no

Edema: yes (pedel oedema)

Questions from patient

What is reason for shortness of breath?

Is there any medication for sleep?

Questions from my side

How is shortness of breath related to kidney failure?

How is cough related to kidney failure?