General Medicine case 07

 General medicine case 07

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A 42 year old female who used to be daily worker came to OPD with Chief complaints of fever,shortness of breath, pedal edema, weakness, facial puffiness, decreased urine output from 3 days.

History of Present illness:- 

Patient was asymptomatic 6 months back.She developed pedal edema 6 months back with shortness of breath. And also developed decreased urine output from 3 days back.

Routine :- She used to wake up by 5 A.M. Do some household work and by 7 have her breakfast. She would go for work by 8 A.M. Have her lunch by 2 P.M  and continue her work by 5 P.M . Then goes to home by 6 P.M and have dinner by 8 P.M and sleep by 10 P.M.

Past History:- 

Patient was hypertensive since 6 months back.

No history of Diabetes.

No history of Tuberculosis, Asthma, Epilepsy.

No history of thyroid.

Personal history:- 

Sleep is normal.

Appetite is normal.

Mixed diet.

Bowel movements regular.

Bladder movements irregular.

No addictions.

Family History:-

No members in family has similar complaints.

Treatment History:-

The Patient had taken medication on Hypertension.

She is not know of any drug allergy.

General examination:-

Patient is conscious, alert and coherent

Patient was well oriented.

No pallor, anemia, cyanosis,icterus, clubbing of fingers.

No generalised lymphadenopathy.

Pitting pedal edema is present.

Vitals:-

Temperature:-afebrile

Pulse rate:-84 beats per min.

Respiratory rate:-24 cycles per min

Blood pressure:-150/80 Hg mm

Systemic Examination:- 

CVS -- Cardic sounds s1, s2.                                           No Cardiac murmurs heard

Respiratory system --- No Dyspnoea.                                                             No wheezing sound.                                         Position of trachea is central

CNS ---- Patient is conscious.                                                   Speech is normal.                                                      Reflexes are normal 

Abdomen--- abdomen is not tender.                                            Reflexes are normal.                                                  Bowel sounds heard.                                                  no palpable mass or free fluid.

Investigations:- 

Provisional diagnosis:-      

Chronic kidney disease.

Treatment:- 

 Inj. LASIX 40 mg IV/BD

TAB. NICARDIA 10 mg PO/TID

TAB. OROFER- XT PO/BD

INJ. Erythropoietin 4000 IU S/C once weekly

TAB. NODOSIS 550 mg PO/BD

TAB. SHELCAL 500 PO/ OD

Fluid restriction upto 1 lit/ day

Salt restriction < 2 gm / day