Case history- 12
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A 50 year old male patient came to OPD with chief complaints of shortness of breath, swelling of legs and decreased urine output since 1 year.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back and then he noticed shortness of breath, swelling of legs, decreased urine output, giddiness and weakness since 1 year.
No history of palpitations and burning micturition.
PAST HISTORY:
Patient is hypertensive since 4 years.
No history of diabetes, CAD, asthma, TB, epilepsy, thyroid disorders.
No history of any surgeries in the past.
PERSONAL HISTORY:
Appetite: low
Diet: vegetarian
Sleep: inadequate
Bowel and bladder movements: regular
Micturition: decreased urine output
Addictions: Alcohol consumption and
smoking since 20 years.
FAMILY HISTORY:
There is no history of similar complaints in the family.
TREATMENT HISTORY:
Patient was on regular medication for hypertension. 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 icterus, cyanosis, clubbing and generalised lymphadenopathy.
Pallor - present
There is bipedal edema of pitting type.
VITALS:
Temperature: afebrile
Blood pressure: 140/90 mm Hg
Pulse rate: 86 beats / min
Respiratory rate: 16/ min
Spo2 : 98% at room temperature
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:
COMPLETE BLOOD PICTURE
LIVER FUNCTION TEST
HBsAg- RAPID
RFT
DIAGNOSIS:
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