Case history- 10
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A 58 year old male patient came to OPD with chief complaints of shortness of breath since 1 month and swelling of legs since 2 years.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 years back and then he noticed shortness of breath since 1 month and swelling of left upper limb since 4 months and legs since 2 years.
PAST HISTORY:
Patient is a known case of hypertension since 4 years.
No history of diabetes, CAD, asthma, tuberculosis, thyroid disorders.
No history of any surgeries in the past.
PERSONAL HISTORY:
Appetite: normal
Diet: mixed
Sleep: adequate
Bowel and bladder movements: regular
Micturition: normal
Addictions: no
FAMILY HISTORY:
There is no history of similar complaints in the family.
TREATMENT HISTORY:
Patient was on medication for hypertension since 4 years.
He 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 lymphadenopathy
Edema is present and of pitting type.
VITALS:
Temperature: 98.4°F
Blood pressure: 130/70 mm Hg
Respiratory rate: 24/ min
Spo2: 98% at room temperature
Pulse rate: 82 beats / min
GRBS: 126 mg%
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
No thrills
S1 and S2 sounds are heard
No cardiac murmurs
RESPIRATORY SYSTEM:
Dyspnoea- no
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:
SERUM IRON
RFT
DIAGNOSIS:
Chronic kidney disease on maintenance hemodialysis
TREATMENT:
1. Fluid restriction < 1.5 lit/ day
2. Salt restriction < 2gm / day
3.Tab. NICARDIA 10 mg TID
4. Tab. LASIX 40 mg OD
5.Tab.SHELCAL OD
6. Tab. NODOSIS 500mg BD
7.Tab. BIO D3 OD
8. Inj. ERYTHROPOIETIN weekly once
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