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A 72 yr old male patient agriculture by occupation presented to the opd with chief complaint of pedal edema , shortness of breath and decreased urine output since 20 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 yrs back. Patient complaints of shortness of breath, decreased urine output,and pedal edema since 20 days
Patient noticed the swelling in his leg and has joint pains and he visited local hospital and medication was taken at that time patient was diagnosed with diabetes and hypertension.
After that patient patient suffers with shortness of breath and has visited to another hospital and was diagnosed as kidney disease. 6-7 times Dialysis was done.
As due to low socioeconomic status patient comes to our hospital on 20/8/21 with similar complaints since 20 days
- There is history of weight loss
-There is no history of cough and fever
-patient complaints of burning micturition due to decreased urine output
- patient says that swelling has subsided by medication
PAST HISTORY
- Patient is known case of hypertension and diabetes and COPD
- There is no history of surgery
- There is no history of epilepsy,asthma,TB
- Patient gives history of blood transfusion due to blood loss
TREATMENT HISTORY
Patient takes medicine for hypertension 10 mg clonidipine and diabetes 50mg vildagliptin
PERSONAL HISTORY
- Appetite is normal
- Diet is mixed
- Sleep is adequate
- Decreased urine output
- Patient was alcoholic and cigarette smoker but he has stopped due to health issues
FAMILY HISTORY
There is no history of similar complaints in the family members. There is no history of death in family due to cancer
GENERAL PHYSICAL EXAMINATION
Patient was conscious, and un cooperative patient is moderately nourished with truncal obesity with muscle wasting. Patient is unable to walk as there is swelling in his joints. And weakness in general
- Anemia present
- pallor present
- dyspnea present
- No clubbing
- No cynosis
- No generalized lymphadenopathy
Bilateral pedal edema present
VITALS
Temperature - afebrile
Pulse rate- 98 /min
Respiratory rate-22/min
Blood pressure-140/90mm Hg
SpO2 at room air- 98%
GRBS- 140 mg%
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
Truncal obesity
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal
PROVISIONAL DIAGNOSIS
Chronic kidney disease
Complete urine examination
Complete blood picture
Serum creatinine
Blood urea
Serum electrolyte
Ultrasound Report
FINAL DIAGNOSIS
Chronic kidney failure on MHD
TREATMENT
Tab lasix - 40 mg BD
Nicardia- 20mg OD
Nodosis- 500mg BD
Shecal - 500mg OD
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