Case history- 3
21 September, 2021
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A 60 year old male patient came to OPD with chief complaints of swelling of the legs , facial puffiness , decreased urine output and shortness of breath.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 months back and then he noticed swelling of legs, facial puffiness, decreased urine output and shortness of breath.
PAST HISTORY:
He is a hypertensive patient since 2 months.
No history of diabetes, CAD, asthma, TB, epilepsy, thyroid disorders.
No history of surgeries in the past.
PERSONAL HISTORY:
Appetite: low
Diet: mixed
Sleep: adequate
Bowel and bladder movements: regular
Micturation: normal
Addictions: no
FAMILY HISTORY:
There is history of hypertension in the family.
TREATMENT HISTORY:
Patient had not undergone any treatment prior. He is not allergic to any known drugs.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time , place and person.
There is no signs of pallor, icterus, cyanosis, clubbing and generalised lymphadenopathy.
There is bipedal edema of pitting type.
VITALS:
Temperature: afebrile
Blood pressure: 140/ 80 mm of Hg
Respiratory rate: 18/ min
Pulse rate: 92/ min
SPO2: 98% at room temperature
GRBS: 147 mg%
SYSTEMIC EXAMINATION
CARDIO VASCULAR SYSTEM:
No thrills
S1 and S2 sounds are heard
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnoea
No wheezing sounds
Position of trachea- central
Breath sounds- vesicular
ABDOMEN:
Shape of abdomen- scaphoid
Tenderness- no
Palpable mass- no
Hernial orifices- normal
Free fluid- no
Bruits- no
Liver- not palpable
Spleen- not palpable
Bowel sounds- yes
CENTRAL NERVOUS SYSTEM:
Level of consciousness: conscious
Speech : normal
Signs of meningeal irritation-
Neck stiffness- no
Cranial nerves- normal
Motor system- normal
Sensory system- normal
INVESTIGATIONS:
Chronic kidney disease on maintenance hemodialysis
TREATMENT:
1. Tab. Shelcal
2.Tab. Nodosis
3. Tab. Lasix
4. Tab. Pantop
5. Inj. Erythropoietin weekly twice
6. Inj. Iron sucrose any weekly once
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