Short case final general medicine
Date of Admission- 05 -02-22
A 25 year old Male presented to OPD with chief complaints of vomitings 10 episodes and bipedal edema and decreased Urinary output since 3 years .
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years ago then he developed multiple episodes of vomitings for which he was admitted in the hospital and found to have high BP of 170 mm Hg .
HISTORY OF PAST ILLNESS
Known history of hypertension .
Known history of Tuberculosis
No history of Diabetes mellitus asthma, epilepsy.
No history of surgeries, chemotherapy or radiotherapy
PERSONAL HISTORY
Diet - Mixed
Appetite- Normal
Bowel movement is regular .
Micturition - Normal
Addictions- None
Sleep - Regular
FAMILY HISTORY
No history of DM, CAD, Asthma and thyroid disorders in the family
GENRAL EXAMINATION
Patient is conscious, coherent, co-operative.
There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy
VITALS
Temperature- 98.4
Pulse rate- 78 bpm
Respiratory rate - 13cpm
BP- 130/80 mm Hg
Spo2- 98%
GRBS -112mg/dl
SYSTEMIC EXAMINATION:
Cardiovascular System
Cardiac sounds- S1, S2 are heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- No
ABDOMEN
Shape of abdomen - Scaphoid
No tenderness
Free fluid- none
Liver- Not palpable
Spleen- Not palpable
Bowel sound- Heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech- normal
No sign of meningitis
Investigations:
Provisional diagnosis- chronic kidney disease
TREATMENT
Conservative- Maintaince Heamodialysis
On 05 -02-22
Fluid restriction < 1L / day
Salt restriction < 2.4 g / day
Tab. Nicardia 10 mg BD
Tab . Lasix 40 mg BD
Tab . Shelac OD
Tab . Pan 40 mg OD
Tab . Ororex XT OD
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