Case of 56 years old male with complaints of SOB since 20 days
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CHIEF COMPLAINT:
56 year old male patient came to OPD with cheif complaints of shortness of breathe,decreased urinary output,Bilateral pedal edema since 20 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 months back then developed bilateral pedal edema which is pitting type and associated with shortness of breathe (grade 2& grade 3 type) not associated with orthopnea or paroxysmal nocturnal dyspnea.
Patient was diagnosed with CKD 3 months back and was on conservative management and was not willing for dialysis.
Now admitted in the hospital for dialysis.
HISTORY OF PAST ILLNESS:
He was a know case of hypertension since 6 months .
FAMILY HISTORY:
There is no similar complaints in the family.
PERSONAL HISTORY:
Diet - Mixed
Appetite- Normal
Sleep- adequate
Bowel & bladder-regular
No Addictions
TREATMENT HISTORY:
He is not allergic to any know drugs.
He was on medication for hypertension.
GENERAL AND PHYSICAL EXAMINATION :
Patient was conscious,coherent, cooperative .
Presence of pallor
No cyanosis
No icterus
No clubbing
Edema: Bilateral pedal edema upto knees.
VITALS:
Temperature: 98.5°F
Pulse rate : 99/min
Respiratary rate: 18/min
BP:160/90 mmHg
SPO2 96%
GRBS: 115mg%
SYSTEMIC EXAMINATION:
CVS: no thrills, s1, s2 sounds heards, no cardiac murmers
Respiratory system:
Dyspnoea
No wheeze
Breath sounds - vesicular
ABDOMEN:
Shape of abdomen - scaphoid
No tenderness
Hernial orifice normal
No free fluid
No bruits
Liver & spleen not palpable
CNS:
Conscious
Speech -Normal
PROVISIONAL DIAGNOSIS:
Chronic Renal Failure
INVESTIGATIONS:
Final Diagnosis: Chronic kidney disease
TREATMENT:
Salt restriction <2.4gm/day
Fluid restriction <1lit/day
Tab. Lasix 40mg /PO/TID
Tab. Nodosis 550mg /PO/BD
Tab. Orofer XT/PO/OD
Tab shellal 500mg /PO/OD
Inj. Iron serum 1 amp in 100 ml (daily dialysis).
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