Case history - 7
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A 53 year old male patient came to the casuality with chief complaints of fever and shortness of breath , pedal edema since 1 month.
History of present illness :
Patient was apparently asymptomatic 1 month back then he developed fever , shortness of breath , pedal edema.
Fever has subsided after using medication .
No history of decreased urine output.
PAST HISTORY :
History of hypertension since 1 month .
No history of - Diabetes mellitus
CAD
Epilepsy
History of TB - 2 years back .
PERSONAL HISTORY :
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
No addictions
FAMILY HISTORY :
No relevant family history .
GENERAL EXAMINATION :
Patient was conscious , coherent, cooperative , thin built .
Pallor - present
Icterus - absent
Clubbing - absent
Lymphadenopathy - absent
VITALS :
Temperature - Afebrile
Respiratory rate - 24 / min
Pulse rate - 92 / min
Blood pressure - 140/ 80 mmHg
SpO2 - 98 %
SYSTEMIC EXAMINATION :
CVS :
No thrills
S1 S2 heard
No cardiac murmurs
Respiratory system :
Dyspnea - present
No wheeze
Breath sounds - vesicular
ABDOMEN :
Shape of abdomen - scaphoid
No tenderness
No free fluid
No bruits
CENTRAL NERVOUS SYSTEM :
Level of consciousness - conscious
Speech - normal
Neck stiffness - absent
INVESTIGATIONS :
Provisional diagnosis :
Chronic kidney failure on maintenance hemodialysis.
TREATMENT :
Tab LASIX
Tab PAN
Tab OROFER
Inj Erythropoietin
Tab NODOSIS
Tab SHELCAL
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