Case history-6

 4 th October, 2021

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A 49 yrs old female presented to the opd with chief complaints of  shortness of breath, facial puffiness, and pedal edema.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 months back , then developed pedal edema , facial puffiness, weakness.

Patient consulted nearby hospital in nalgonda and was diagnosed with kidney failure and HTN

Patient continued taking medication for HTN suggested there.

3 days back patient presented to the opd with shortness of breath , pedal edema , facial puffiness.

On friday ( 1/10/21) patient has undergone  dialysis.. followed by sunday (3/10/21) second dialysis was done.

PAST HISTORY:

There is no history of asthma, seizures, tuberculosis, CAD.

Patient is a known case of hypertension.

There is no history of any surgeries.

PERSONAL HISTORY:

Appetite- lost

Sleep- not adequate

Diet- mixed

Bowel movement- regular

Decreased urine output.

Patient takes alcohol occasionally.

FAMILY HISTORY:

No similar complaints in the family.

GENERAL EXAMINATION:

No cyanosis

No lymphadenopathy

No clubbing

No icterus

Mild dehydration is seen.

VITALS:

Temperature: 98.6 degrees celsius.

Pulse rate: 112 beats/min 

BP: 170/110

Respiratory rate: 28 breaths/min

SYESTEMIC EXAMINATION:

CVS:

No thrills

S1S2 heard.

RESPIRATORY SYESTEM:

Dyspnea- Yes

Wheez- Yes

Breath sounds- vesicular

Postion of trachea- central

ABDOMEN:

Shape of abdomen- Scaphoid

No tenderness

No palpable mass

Hernial orifices- normal

CNS:

Level of consciousness- conscious

Speech- normal 

No neck stiffness

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

Chronic kidney disease.

TREATMENT:

1.Hydrocortisone IV 100mg 

2. Inj.Lasix

3. Inj.NTG IV

4.Nebulizer- Duolin

5. Nebulizer- Budecort.