General medicine case 3
September 13,2021
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September 13,2021
A 60yr old male presented to the opd with cheif complaint of pedal edema, facial puffiness and decreased urine output from the past 10days.
HISTORY OF PRESENT ILLNESS
The patient was apparently asymptomatic 6momths back and developed pedal edema, facial puffiness, decreased urine output and shortness of breath.
PAST HISTORY
No history of diabetes and tuberculosis
Known case of hypertension
PERSONAL HISTORY
loss of appetite
Mixed diet
Sleep is inadequate
Patient was alcoholic and stopped drinking from last 6months
Regular bowel movements
Decreased urine output
FAMILY HISTORY
No history of similar complaints
GENERAL PHYSICAL EXAMINATION
No pallor
No anemia
No clubbing
No cyanosis
No generalized lymphadenopathy
VITALS
Temperature -98.5°C
Pulse rate-92/min
Respiratory rate -18/min
Blood pressure-140/80mm Hg
SPO2-98%
GRBS-147mg%
SYSTEMIC EXAMINATION
CVS
No thrills
S1 & S2 heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Breath sounds - vesicular
ABDOMEN
Shape of abdomen-scaphoid
No tenderness
No palpable mass
No bruits
Bowel sounds are heard
CNS
Speech-normal
Level of consciousness-conscious
PROVISIONAL DIAGNOSIS
CKD on MHD
INVESTIGATIONS
HEAMOGRAM
LIVER FUNCTION TEST
ANTI HCV ANTIBODIES -RAPID
Non reactive
SERUM IRON-82 ug/dl
BLOOD GROUPING - B+ve
HIV 1/2 RAPID - Non reactive
HBsAg Rapid - Negative
RFT -
BLOOD SUGAR - 165 mg/dl
ULTRA SOUND REPORT
TREATMENT
Tab SHELCAL 500mg OD
Tab NODOSIS 500mg BD
Tab OROFER - XT - OD
Tab BIO D3 OD
Tab LASIX 40mg OD
Tab PANTOP 40mg OD
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