Case History 1
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21.03.2022
A 48 year old male who is Tailor by occupation came to OPD with SOB-3 days
profuse sweating since three days
generalised weakness since three days
HISTORY OF PRESENT ILLNESS:
patient was alparently assymptomatic three days back he developed SOB,profuse sweating generalized weakness ,
insidious in onset gradually progressive ,along with this pedal edema present,facial puffiness and upper limb edema and diagonsed with diabetic nephropathy with k/c/o DM type 2 and HTN ,and now pt. came for MHD
B/L pedal edema extending upto knees , pitting type
HISTORY OF PAST ILLNESS
K/C/O-HTN On medication
DM type 2 on medication
TREATMENT HISTORY
The patient is not known case of drug allergy
PERSONAL HISTORY
-The patient has Loss of appetite
-bladder movements are normal
-no sleep disturbances
FAMILY HISTORY
There are no similar complaints in the family members
GENERAL EXAMINATION
-Pt is conscious ,coherent ,cooperative.
-pallor
-no icterus
-no lymphadenopathy
- no cynasis
-no clubbing of fingers
-edema of feet present
VITALS
temp. 98.5'f
PR. 92 bpm
RR. 26 cpm
BP. 130/70 mm/hg
SPO2. 93%
SYSTEMIC EXAMINATION
CVS
-no thrills
-no cardiac murmurs
S1&S2 sounds are heard
RESPIRATORY SYSTEM
- Position of trachea is central
- Bilateral air entry is normal
- Normal vesicular breath sounds hear
- No added sounds
PER ABDOMEN
-abdomen is not tender
-no palpable mass or free fluid
CNS
- Patient is conscious
- Speech is present
- Reflexes are norm
INVESTIGATION
PROVISIONAL DIAGNOSIS
-CKD on MHD
TREATMENT
-salt restriction
- fluid restriction
Tab.NICARDIA 10mg
Tab.NODOSIS 500mg
Tab.SHELCAL CT
Tab.OROFER -XT
Inj.EROYTHROPOETIN 4000iu
Tab.PANTOP 40mg
