60 year old male come to OPD with a complaints of SOB ,bilateral pedal edema decreased urin output since 10 days
November 08, 2022
Name : k. Durga bhavani
Roll no : 35
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A 60 year old male came to OPD with the complaint of SOB, bilateral pedal edema , and decreased urine output since 10 days.
CHIEF COMPLAINT:
complaint of Shortness Of Breath, bilateral pedal edema and decreased urine output since 10 days.
HISTORY OF PRESENT ILLNESS:
patient was apparently asymptomatic ten days back then he experienced shortness of breath (grade 2 and grade 3)with aggravating and relieving factors and decreased urine output
HISTORY OF PAST ILLNESS:
NO similar complaints in past
-k/c/o- HTN since 10 years
-n/k/c/o- Asthma, Epilepsy,TB
PERSONAL HISTORY:
Married
Appetite- normal
Occupation: farmer
Mixed diet
Bowel and bladder: regular
No known relevant allergies
No addictions
FAMILY HISTORY:
No other family member has similar complaint
PHYSICAL EXAMINATION:
GENERAL EXAMINATION:
patient is concious coherent cooperative and well oriented to time place and person
-No pallor
-No lymphadenopathy
-No icteru
-No cyanosis
-pedal edema -present
Vitals:
Temp: 97°f
Pulse rate: 98/min
Respiratory rate: 22cpm
SYSTEMIC EXAMINATION:
CVS:
-No thrills
- No cardiac murmurs
RESPIRATORY SYSTEM:
- No dyspnea
-No wheeze
- Breath sounds- vesicular
-position of trachea-central
ABDOMEN-:
shape of the abdomen: scaphoid
- no tenderness
- no palpable mass
- hernial orifice normal
-no free fluid
- spleen and liver: not palpable
CNS: level of consciousness - conscious
- Speech : normal
- No neck stiffness and no kernings sign
PROVISIONAL DIAGNOSIS:
CKD on mhd.
Plan of care: hemodialysis
INVESTIGATION
Treatment:
Tab: lasix 40 mg
Orofer
Shelcal 500 mg
Bio P3
Inj: erythropoietin 4000IU weekly once
