Case history 10

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A 37 year old male patient came to the casuality with chief complaint of shortness of breath , pedal edema .

History of present illness : 

Patient was apparently asymptomatic 3 months back then he developed shortness of breath ( grade 2 -3 ). 

He developed pedal edema and edema of hands  1 month back.

No history of burning micturition.

Past history : 

History of hypertension since 3 months .

History of low grade fever 3 months back.

History of epigastric pain  1 month back.

No history of diabetes mellitus , CAD , asthma, Tuberculosis , Epilepsy.

Personal history : 

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder movements - normal 

Addictions - non smoker 

                      Occasionally alcoholic - now stopped.

Family history : 

No relevant family history .

General examination : 

Patient was conscious , coherent , not cooperative  and we'll oriented with time , place and person .

Pallor - present

Icterus - absent

Cyanosis - absent 

Lymphadenopathy - absent 

Edema - bipedal edema present 

               Edema of left hand 

VITALS : 

Temperature - Afebrile 

Pulse rate - 88 beats / min 

Respiratory rate - 22/ min 

Blood pressure - 150/90 mmHg 

SYSTEMIC examination : 

Cardiovascular system : 

No thrills 

S1 S2  heard 

No cardiac murmurs 

Respiratory system : 

No dyspnoea  

No wheeze 

Breath sounds - vesicular 

Abdomen : 

Shape of abdomen - scaphoid

No tenderness 

No palpable mass 

Free fluid - no 

No bruits 

Liver - not palpable 

Spleen - not palpable 

Central nervous system : 

Level of consciousness - conscious 

Speech - normal 

Neck stiffness : no 

Investigations : 

Provisional Diagnosis : 

Chronic kidney failure on maintenance haemodialysis .

Known case of hypertension .

Anemia secondary to renal failure.

Treatment : 

Tab Nicardia - 20 mg  TID 

Tab Arkamine - 0.1 mg TID 

Tab Lasix - 40 mg  BD 

Tab Shelcal - CT   OD 

Tab Orofer - XT   OD 

Tab PANTOP - 40 mg  OD 

Inj Erythropoietin - 4000 IU   S/ C  weekly once