General medicine case history-3
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Date of admission : 29/12/2021
A 53 years old female patient presented to opd with chief complaints of SOB from 3days and decreased
Urinary output.
History of present illness :
Patient complaints of productive cough - copious amount of expectoration associated with postural variation more during sleep.
Daily routine of a patient :
Patient wakes up at 6:30 /7 am in the morning takes her breakfast between 9:30 - 11 am and takes her dinner by 8 pm, go to bed by 9pm.
History of past illness :
K/c/o of hypertension since 6 years
No h/o diabetes
No h/o epilepsy
No h/o lymphadenopathy
No h/o asthma
No h/o tb
Personal History :
Appetite : Normal
Diet : Eggtarian
Bowel : regular
Bladder : regular
Sleep : Adequate
No addiction
F
amily history :
No similar complaints in the family.
Drug history :
No allergy to known drugs
General examination:
Patient is conscious,coherent, cooperative.
No Pallor
No cyanosis
No lymphadenopathy
No clubbing
No icterus
No edema
No tremors
Vitals :
Temperature : 98°F
Pulse rate : 86 bpm
BP : 150/90
Respiratory rate : 18 cpm
Systemic examination :
CVS
S1 and S2 sounds are heard
Respiratory system
No dysponea
Position of trachea central .
Abdomen:
Soft and non tender
CNS
Patient is conscious
Speech is normal
Special investigations :
Complete blood picture
Serum iron
Renal functional test
Liver functional test
PROVISIONAL DIAGNOSIS :
CKD on MHD associated with anemia
Treatment :
Fluid restriction <1lit/day
Salt restriction <2.4gm/day
Tab lasix 40 mg /po/BD
Tab Nicardia 10mg
Tab Orofer-Xt po/BD
Tab Nodosin 500mg po/BD
Tab Shelcal-XT po/ OD
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