Case history -4
12 th October 2021
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A 55 year old female patient came to casuality with chief compliant of shortness of breath, pedal edema, facial puffiness.
History of present illness :
Patient was asymptomatic 15 days back then she developed pedal edema,shortness of breath ,facial puffiness for which she got treated. 8 days back she got discharged and developed shortness of breath while doing her daily routine like walking, going to bathroom.
Decreased urine output since 1 day.
No fever, vomitings,loose stools, chest pain.
Past history :
Patient is a known case of diabetes mellitus since 15 years and hypertension since 10 years.
No history of asthma, tuberculosis, CAD.
Personal history :
Diet - mixed
Appetite - normal
Bowel and bladder movements- regular
Addictions- non alcoholic &non smoker
Family history :
No member of the family has similar complaints.
General examination :
Patient is conscious, coherent, cooperative and she is moderately built and nourished.
Pallor - present
Cyanosis - absent
Icterus - absent
Clubbing - absent
Lymphadenopathy- absent
Edema - present
VITALS
Temperature - Afebrile
Respiratory rate - 24/ min
Pulse rate - 100 / min
Blood pressure - 140/90 mm Hg
SYSTEMIC EXAMINATION
Cardiovascular system
No thrills
S1 ,S2 heard
No cardiac murmurs
Respiratory system
Dyspnea - present
No wheeze
Breath sounds - vesicular
Abdomen
Shape of abdomen - scaphoid
No palpable mass
No bruits
No tenderness
CNS
Level of consciousness - conscious
Speech - normal
No neck stiffness
INVESTIGATIONS
Provisional diagnosis :
Urinary tract infection
Renal failure due to nephritic syndrome
Treatment:
Inj PAN
Inj Lasix
Tab Clindipine
Tab Arkamine
Tab Shelcal
Tab Orofer
Inj Erythropoietin
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