Case history-3

13 September, 2021

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A 60 yrs old man presented to the opd with chief complaints of swelling of both the legs, decreased urine output, shortness of breath .

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic  2 months back.

In the month of August ( 17/8/21) , patient was diagnosed with chronic renal failure and has underwent 8 dialysis till date 13/9/21

PAST HISTORY:

No history of diabetes.

No history of any surgeries in the past

Patient is a known case of hypertension.

PERSONAL HISTORY:

Apetite- normal

Diet- mixed

Sleep- inadequate.

Bowel movement- regular

Decreased urine output

Addiction: patient was alcoholic , stopped drinking from past 6 months.

FAMILY HISTORY:

No history of asthma, diabetes, CAD, thyroid , hypertension in the family.

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative

No pallor

No clubbing

Paedal edema is present.

VITALS:

Temperature: afebrile

Pulse rate: 92 beats/min

BP: 140/80 mm Hg

Respiration: 18/ min

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM;

Thrills- no

Cardiac murmur- no

S1S2 heard.

RESPIRATORY SYSTEM:

Wheeze-no

Postion of trachea- central

Breath sounds- vesicular

ABDOMEN:

Shape of abdomen: scaphoid

No tenderness

No palpable mass

CENTRAL NERVOUS SYSTEM:

Speech- normal

Level of consciousness- conscious

Neck stiffness- no

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on MHD

TREATMENT:

1. Tab. Shelcal 500mg OD

2. Tab. Nodosis 500mg BD

3. Tab. Orofer - XT OD

4. Tab. Lasix 40 mg OD

5. Tab. Pantop 40 mg OD