General medicine case 4

I'm Maimuna Fathima,3rd year BDS March 4th,2023

This is an E-log to discuss case scenario of a patient.
I have been given this case to solve in an attempt to understand topic of patient,clinical data analysis to develop my competency in reading and comprehending clinical data including history,clinical findings,investigation and come up with diagnosis and treatment plan.

A 70 years old male,farmer by occupation was brought to the OP because of Shortness of breath and swelling in limbs and face 9 days ago

Chief complaint:
Shortness of breath since 9 days 
Swelling of limbs and face by 9 days 

History of present illness:
Patient was apparently asymptomatic 9 days back then he developed Shortness of breath and generalized swelling in hands,legs and face.He even started feeling difficulty in passing out urine.

History of past illness:
Hypertension since 8 years  
No Diabetes 
No TB

Family history:Not significant 

Personal history:
Diet:Mixed 
Appetite:Decreased 
Bowel and bladder:Irregular 
Sleep:Adequate 
Addictions:None

General examintion:Patient is conscious,coherent,cooperative and well oriented to time place,and person.
Pallor:No
Icterus:No
Cynosis:No
Clubbing:No

Provisional diagnosis:Kidney failure 





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