45 year old male.
Date of admission ; 7/08/2021
CASE :
A 45 yr old male , came to the opd with chief complaints of
Pedal edema since 2 month and
Shortness of breath since 2 month
HISTORY OF PRESENT ILLNESS :
Pt was apparently asymptomatic 2 months back later he developed with facial puffiness, shortness of breath and pedal edema since 2 month.
Pedal edema which is gradual in onset,progressive in nature ,pitting type upto knee .
SOB since 1 month - grade 2 dyspnea.
PAST HISTORY :
Not a k/c/o of diabetes ,tb, epilepsy, asthma
k/c/o HTN-1 year.
PERSONAL HISTORY :
Married
Sleep : adequate
Appetite : Decrease, stopped taking non veg food.
Bowel and bladder movements : regular
Alcohol and tobacco consumption:
History of alcoholic consumption: occasional
No history of tobacco consumption
FAMILY HISTORY :
No significant family history
GENERAL EXAMINATION
Physical examination:
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
Pedal edema is noticed which is of pitting type progressive in nature,extending up to the knees
Pallor present
No signs of icterus ,cyanosis , lymphadenopathy, malnutrition, dehydration
Pulse = 82 beats per minute, regular.
- Blood pressure = 140/90 mm of Hg
- Respiratory rate = 18 cycles per minute
-SPO2=98%
-GRBS=109mg%
Systemic Examination:-
CVS:
S1,S2 heard
No Thirlls and murmurs.
RESPIRATORY :
position of trachea-Central.
Breath sounds- vesicular
ABDOMEN:
Shape: Scaphoid.
No tender and palpable mass.
CNS:
Provisonal diagnosis :
Chronic renal failure.
INVESTIGATIONS:
1) ECG:
2)ECHO:
3) REPORT
COMPLE BLOOD PICTURE
COMPLETE URINE EXAMINATION
SERUM IRON
SERUM CALCIUM
PHOSPHORUS
SERUM CREATININE
LIVER FUNCTION TESTS
HBsAg- RAPID
SERUM ELECTROLYTES
ANTI HCV ANTIBODIES- RAPID
BLOOD UREA
EXAMINATION:
1) PALLOR
2) PITTING EDEMA
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