CASE SCENARIO

Pt aged 60 yrs M farmer by occupation came came opd with chief complaints of SOB 10 days and decreased loss appetite since 10 days and sleep disturbances since 10 days lower backache since 10 days
Fever since 4 days.

HISTORY OF PRESENT ILLNESS

•Pt was apparently normal 9 yrs back then developed HTN;
•1 yr back pt developed lower flank pain on both sides went toprivate hsptl then since Aug 2021 then pt was on dialysis 
•3 yrs back pt had a seizure on midnight in sleep and since then he was on PHENYTOIN 

HISTORY OF PAST ILLNESS

Pt know case of HTN since 9 yrs

Pt is on femoral line since August 2021

N/k/c/o DM

TREATMENT  HISTORY 

Pt is on hypertensives and PHENYTOIN 

PERSONAL HISTORY 

Mixed diet

Occasional alcohol drinker

PHYSICAL EXAMINATION 

Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

                       Icterus



VITALS


•Temp - afebrile 

•Pulse rate - 76 BPM

•RP - 24/min

•BP - 140/80 mm hg

•SPO2 - 96 %

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

 

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected 

 

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