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CASE SCENARIO:
56yr old male patient resident of chanduputta , farmer by occupation, came with chief complaints of bilateral pedal edema since 1month ,fever and burning micturition Since 1 month
History of presenting illness:
Patient was apparently asymptomatic 1 month back then he developed pedal edema which is Bilateral then he developed fever low grade intermittent associated with burning micturition since 20 days .
No complaints of decreased urine output, hematuria,loin pain
k/c/o Chronic kidney disease 3yrs
History of past illness:
N/k/o diabetes mellitus, HTN ,epilepsy ,thyroid ,CAD
TREATMENT HISTORY:Not significant
PERSONAL HISTORY:
Married
Occupation: farmer
Diet: Mixed , Non vegetarian
Appetite: Normal
Bowels: regular
Micturation: normal and complaints of burning micturition since 1 month
Known Allergies: No
No addictions.
General Examination.
No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema
Vitals:
Temperature - 98.6F
BP:-110/80mmhg ,
PR:- 84bpm,
RR- 16 cpm,
Spo2:-99%
GRBS:107mg%
Systemic examination:
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM
Dyspnoea:No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
ABDOMEN
Shape - Scaphoid
No tenderness and palpable mass, No Fluid
CNS Examination:
Conscious coherent cooperative.
Speech normal.
No signs of meningitis
Cranial nerves, motor system, sensory system Normal.
PROVISIONAL DIAGNOSIS:
Treatment history:
Vitals:Bp
Temperature - 97.7F
BP:-110/80mmhg ,
PR:- 84bpm,
RR- 18 cpm,
Spo2:-99%
CVS:S1 S2 heard
CNS: No focal Neurological deficit
RS: Normal Vesicular breathe sounds
PA:soft nontender
Prescribed:
•Salt restriction in diet <2gm/day
•Fluid restriction <1.5lt/day
•Inj ERYTHROPOIETIN 400U/Sc/weekly
•Tablet Lasix40mgPO/TID
•Tablet. NODOSI 500mgPO/BD
•Tablet. SHELCAL 500mgPO/OD
•Tablet.OroforXT PO/OD
•CAP.BioD3Po/weekly once
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