Case history -6

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Chief complaint:

A 40 year old male Patient of came to casualty with chief complaint of facial puffiness and  pedal edema since one month,shortness of breath since 3 days.

History of present Illness.pt was apparently well one month ago.then he had pedal edema and facial puffiness.he then was admitted to nalgonda govt hospital and was referred to KIMS for further treatment.

History of past illness: a known case of HTN, not a known case of asthma,TB, Diabetes

Has a history of NSAIDS usage since 15 years.

Personal history:

Pt takes mixed diet with  lost appetite,irregular bowel movements..irregular bladder movements.

No habits of smoking .

Regular toddy consumer.

family history:

No relevant family history

Treatment history:

No drug allergy to any known drugs.

General examination:

Pt is conscious, coherent and cooperative.he is moderately built and well oriented in place and time.

Signs of pallor and clubbing.no signs of cyanosis, lymphadenopathy .signs of bilateral pedal edema of pitting type.

Vitals

Temp:afebrile

BP:130 /90 mmhg

Pulse rate:96 BPM

Respiratory rate:17 cycles per min

Systemic examination:

CVS:

no thrills,no cardiac murmurs,

 S1 and S2 are heard

Respiratory system:

No dyspnoea and wheezing is present.

Centrally positioned trachea,vesicular breath sounds

Abdomen:

Schaphoid abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.

CNS:

Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves.

Provisional diagnosis:

Chronic kidney disease

Investigations:

Treatment: 

Salt restoration <2gm/day

 Fluid restoration <1.5 lit /day 

TAB. LASINO 40mg.PO/BD

TAB. NICARDIA 20 mg PO/BD

TAB. PAN 40 mg PO/BD

TAB. OROFER xT PO/BD

TAB .NODOSIN 500mg PO/OD

INJ ERYTHROPOIETIN 4000 IU/SU/weekly once

TAB SHELCAL CT PO/BD

Cetrizine Po *TID

Benadryl 5ml *TID