General medicine case history-6
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Date of admission : 19/02/2022
A 68 yrs male patient who is resident of nalgonda presented to opd with a chief complaint of bilateral pedal edema and shortness of breathe since 15 days.
History of present illness :
Patients daily routine:
Patient wakes up around 4 -5 am in the morning and takes his breakfast by10 am , lunch by 2pm and dinner at 8 pm and goes to bed by 9:30pm.
Patient was apparantly asymptomatic 10years back then he fell from tractor while working (so he stopped farming) and he had right hip fracture for which no surgery was performed. He used NSAIDS 3months for his hip pain .
He also diagnosed with hypertension 10 years back and on CLONIDINE (dec2019)and NICARDIA (2020).
He had pedal edema and shortness of breath 2 years back and visited to hospital (urea :26 , creatinine: 2.8, hemoglobin : 7.3) then he advised to start hemodialysis, and he underwent 10 sessions of hemodialysis on dec 2019 and Jan 2020. After that he advised to stop his dialysis sessions as was doing symptomatically better. And he was doing better from jan 2020 to Feb 2022.
No history of diabetes, asthma, epilepsy, tuberculosis.
Personal history:
Diet : vegetarian
Appetite : normal
Sleep : adequate
Bowel& bladder movements : regular
Addictions : used to be alcoholic (not now) and he is a smoker(2-4 cigarettes/day).
Family history:
No relevant family history
Drug history :
No allergy to known drugs
General examination:
Patient of coherent,cooperative and conscious
No Clubbing
No Icterus
No lymphadenopathy
No pallor
No cyanosis
Vitals :
Temperature-afebrile
Bp-110/80mm/hg
Pulse rate -98beats/min
Respiratory rate -18 cycles/min
Systemic examination:
CVS:s1&s2 are heard
no thrills and murmurs heard.
Respiratory system :
No wheeze , dyspnoea
position of trachea central.
Abdomen:
CNS:
patient is conscious and coherent.
Speech normal .
PROVISIONAL DIAGNOSIS :
Ckd on MHD
Investigations :
19/02/2022
23/02/2022
Treatment :
T. PAN 40mg po/OD
T. LASIX 40 mg po/BD
T. OROFER XT po/OD
T. NODOSIS 500mg BD
T. SHELCAL PO/OD
T. MVT PO/OD
T. NICARDIA 20mg PO/BD
Monitor vital
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