Case presentation 8
19.11.21
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Chief complaint:
A 40 year old male Patient of came to casualty with chief complaint of facial puffiness and pedal edema since one month,shortness of breath since 3 days.
History of present Illness.pt was apparently well one month ago.then he had pedal edema and facial puffiness.he then was admitted to nalgonda govt hospital and was referred to KIMS for further treatment.
History of past illness: a known case of HTN, not a known case of asthma,TB, Diabetes
Has a history of NSAIDS usage since 15 years.
Personal history:
Pt takes mixed diet with lost appetite,irregular bowel movements..irregular bladder movements.
No habits of smoking .
Regular toddy consumer.
family history:
No relevant family history
Treatment history:
No drug allergy to any known drugs.
General examination:
Pt is conscious, coherent and cooperative.he is moderately built and well oriented in place and time.
Signs of pallor and clubbing.no signs of cyanosis, lymphadenopathy .signs of bilateral pedal edema of pitting type.
Vitals
Temp:afebrile
BP:130 /90 mmhg
Pulse rate:96 BPM
Respiratory rate:17 cycles per min
Systemic examination:
CVS:
no thrills,no cardiac murmurs,
S1 and S2 are heard
Respiratory system:
No dyspnoea and wheezing is present.
Centrally positioned trachea,vesicular breath sounds
Abdomen:
Schaphoid 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.
Provisional diagnosis:
Chronic kidney disease
Investigations:
Treatment:
Salt restoration <2gm/day
Fluid restoration <1.5 lit /day
TAB. LASINO 40mg.PO/BD
TAB. NICARDIA 20 mg PO/BD
TAB. PAN 40 mg PO/BD
TAB. OROFER xT PO/BD
TAB .NODOSIN 500mg PO/OD
INJ ERYTHROPOIETIN 4000 IU/SU/weekly once
TAB SHELCAL CT PO/BD
Cetrizine Po *TID
Benadryl 5ml *TID
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