Case history :4

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Date of examination28/10/2021

  A 45yrs male came to OPD with chief complain of  shortness of breath, bipedal oedema, facial puffiness.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months ago then developed shortness of breath,bipedal oedema, facial puffiness.

Patient was diagnosed as AKI on CKD and dialysis has initiated.

HISTORY OF PAST ILLNESS:

Patient has thyroid since 1 yr, diabetis and hypertension since 6 yrs.

Not a known case of TTS,Asthama and Epilepsy

No history of surgeries and blood transfusions in the past.

PERSONAL HISTORY:

Appetite: normal.

Sleep: inadequate.

Diet: mixed

Bowel movement: regular.

No addictions.

Bladder movement: burning micturition.

FAMILY HISTORY:

No history of diabetes, stroke, asthma, heart disease, cancer, tuberculosis.

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative 

Pallor, Pedal Edema , clubbing are present.

VITALS:

Temperature: 98.4° F

Pulse rate: 84/min

Respiratory rate: 24/min

BP : 140/90 mmHg

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Thrills and murmurs: no.

S1 and S2 heard.

RESPIRATORY SYSTEM:

Dyspnoea: no.

Wheeze: no.

Position of trachea: central.

ABDOMEN:

Shape : scaphoid

No tenderness and palpable.

CNS:

Level of consciousness: conscious

Speech: normal.

PROVISIONAL DIAGNOSIS:

CKD on MHD.

INVESTIGATIONS:

Hemogram:

Treatment:

Tab lasix.

Tab mete-XL.

Tab thyromin.

Tab urogen.