Prefinal case history



A 50 years old male patient came to casualty with shortness of breath since 4-5 days , low backache since one week and intermittent fever not associated with chills.

History of present illness:

No cheif complaint of burning micturition

And a known case of  chronic kidney disease since three years and on conservative management

History of past illness:

Known case of Hypertension since three years 

Not a known case of asthma, TB ,diabetes 

Personal history: adequate diet before development of symptoms mixed diet 

Regular bowel and bladder movements 

Sleep adequate 

Has Habit of smoking and alcohol 

Family history:

No family history 

No cases of HTN and DM  

Treatment history: previously seen by a doctor and subsides on medication 

PHYSICAL EXAMINATION

GENERAL 

Patient is coherent, cooperative and conscious.

proper nourishment and proper build is seen.

pallor - Present 

Icterus    - absent

Lymphadenopathy- absent

clubbing - absent

cyanosis - absent

Pedal edema  - Present 

VITALS:

Afebrile

BP- 170/100 mm Hg

PR-99 bpm

RR- 22 cpm 

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM-shortness of breath

CVS-S1,S2 +

RR- 16cpm

Spo2 -98%

RS: BAE+

P/A: SOFT, NON TENDER

CNS- NAD 

Provisional diagnosis:

Chronic Renal failure 

HTN 








Treatment

 Fluid restriction <1L per day 

Lasix-40mg 

Nicardia -20mg 

Salt restrictions<2.4g/day










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