CASE HISTORY- PREFINALS
21 December , 2021
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Date of admission: 17/12/21
A 35 yrs old female presented to the opd with chief complaints of pedal edema , shortness of breath , decreased urine output
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back , then developed pedal edema and shortness of breath .
Patient visited nearby hospital in Miryalguda and was suggested with medications
Since last 20 days patient complains of pedal edema, shortness of breath , decreased urine output.
Patient also complains swelling and pain in the abdomen since last 3 days.
PAST HISTORY:
No history of similar complaints in the past
No history of diabetes, tuberculosis, coronory artery disease , epilepsy
Patient is a known case of hypertension since 1 month
FAMILY HISTORY:
No history of similar complaints in the family.
PERSONAL HISTORY:
Appetite - normal
Diet - mixed
Bowel movement- regular
Sleep - adequate
No addictions
GENRERAL EXAMINATION:
Patient is conscious, coherent and cooperative
No clubbing
No icterus
No cyanosis
No lymphadenopathy
VITALS:
Temperature: 98.5 F
Respiratory rate- 22 breaths/min
Pulse rate- 99 beats/min
BP- 170 /100 mm of Hg
SYSTEMIC EXAMINATION:
CVS:
No thrills
S1 S2 heard
RESPIRATORY SYSTEM-
No dyspnea
No wheeze
Position of trachea- Central
Breath sounds- vesicular
ABDOMEN-
Shape - Scaphoid
No tenderness
No palpable mass
Liver and spleen not palpable
CNS-
Level of consciousness- conscious
Speech - normal
No neck stiffness
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
AKI on CHD
TREATMENT:
Inj. Lasix
Tab. Nicardia
Inj. Piptaz
Tab. Nodosis
Tab. Shelcal
Tab. Orofer
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