65 year old male patient with c/o pedal edema and burning micturition.
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Name : k Durga bhavani
Roll no : 35
25th April,2022.
Name : Durga bhavani
65 year old male patient came with chief complaint of pedal edema and burning micturition.
HISTORY OF PRESENT ILLNESS. ;
Patient was apparently asymptomatic 1 month back then he developed pedal edema and burning mixturation .
HISTORY OF PAST ILLNESS ;
Patient was apparently asymptomatic 1 year back then he developed a slight back pain and decreased urine output . He went to the local hospital and the symptoms will subside after taking medicine and he diagnosed that he has a kidney problem.
TREATMENT HISTORY:
- He took the medicine for kidney problem
1 year back
- He is using medicine for Hypertension
PERSONAL HISTORY :
- He is married.
- occupation : milk vender
- Has normal appetite.
- Has regular bowels
- Has decreased and burning micturition
- No known allergies
- No addictions
FAMILY HISTORY :
His wife has diabetes
ON EXAMINATION
- patient was concious coherent and
Comparative
- speech - Normal
- pallor - present
- icterus. - absent
-Clubbing - absent
- cyanosis - absent
- lymphadenopathy - absent
- malnutrition and edema - present
VITALS ;
BP :130 / 90 mmHg
Temp. : 98.6 °F
SpO2 : 98 %
RR. : 92 cycles / min
PR : 20 bpm
SYSTEMIC EXAMINATION. :
CVS :
- S1 ,S2 sounds are Heard
- No cardiac murmurs and thrills
RESPIRATORY SYSTEM :
- No dyspnoea
- Wheezing is present
- position of trachea - central
ABDOMEN :
- No tenderness , palpable mass
- No palpable liver and spleen
PROVISIONAL DIAGNOSIS
TREATMENT :
20 - 04 - 22.
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .PRAZOPEN 5 mg po BD
TAB .MONOXINEDINE PO BD
TAB .OROFERXT po OD
TAB . SHELCAL po OD
TAB .NODOSIS 10 mg po OD
21-04- 22
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .PRAZOPEN 5 mg po BD
TAB .MONOXINEDINE PO BD
TAB .OROFERXT po OD
TAB . SHELCAL po OD
TAB .NODOSIS 10 mg po OD
22-04-22
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .NODOSIS 10 mg po OD
23 -04- 22
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .PRAZOPEN 5 mg po BD
TAB .MONOXINEDINE PO BD
TAB .OROFERXT po OD
TAB . SHELCAL po OD
TAB .NODOSIS 10 mg po OD
TAB . PREGABALIN 75mg po OD
24 -04- 22
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .PRAZOPEN 5 mg po BD
TAB .MONOXINEDINE PO BD
TAB .OROFERXT po OD
TAB . SHELCAL po OD
TAB .NODOSIS 10 mg po OD
TAB . PREGABALIN 75mg po OD
25 -04 -22
Inj. Lasix 40 mg IV BD
TAB . NICARDIA 10 mg po OD
TAB .PRAZOPEN 5 mg po BD
TAB .MONOXINEDINE PO BD
TAB .OROFERXT po OD
TAB . SHELCAL po OD
TAB .NODOSIS 10 mg po OD
TAB . PREGABALIN 75mg po OD
