Case presentation 2
21.09.21
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Date of admission:17/09/21
A 80yr old Male patient came to ward with chief complaints of fever since 15 days loss of appetite since 13 days.
History of present illness:
Pt was apparently asymptomatic 15 days back after which he developed fever and avoided taking food completely due to loss of appetite and frequent urination.
Past history:
Pt had no similar complaints in the past.pt is known case of hypertension.
He is not a known case of asthma, epilepsy,thyroid, tuberculosis,CAD and CVD.
History of hospital visit for fever.
Personal history:
Patient takes mixed diet with poor appetite.normal bowel and increase bladder movements.
Chronic alcoholic and smoker since 40 years.smokes a bundle of cigars per day and consumes a peg every day.
Treatment history:
No history of allergy to any known drug.
On examination:
Patient is conscious,coherent, cooperative.well oriented to time ,place, person
Thin built and and looks malnourished
Temperature: afebrile
BP:140/90 mm of hg
pulse rate:90 beats per min
Respiratory rate:20 per min
CVS:
no thrills,no cardiac murmurs,
S1 and S2 are heard
Respiratory system:
No dyspnoea and wheezing
Centrally positioned trachea,vesicular breath sounds
Abdomen:
schaphoid shape of abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.
CNS:
Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves.
Glasgow scale 15/15
Provisional diagnosis:
Chronic renal failure
Investigations:
Complete blood picture
Blood urea : # 214 mg/ dl
Serum creatinine : # 14 mg/dl
Serum electrolytes :
Sodium : 140 mEq/L
Potassium : # 5.7 mEq/L
Chloride : # 96 mEq/L
Treatment:
Fluid restriction :<1.5 L/day
Salt restriction:<2gm/day
T.CLINIDIPINE 10mg BD
T.NODOSIS 500 mg BD
T.BIO D3 OD
BP,PR,SPO2,Temp monitoring
T.PLM 650mg BD
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