A 50 years old male patient with shortness of breath
Jan 2 2023
A 50 yr old male daily labourer by occupation came with chief complaints of shortness of breath since 10 days
HOPI
Patient was apparently asymptomatic 1 yr back
Then he developed fever for which he went to the hospital and was diagnosed with chronic kidney disease and is on conservative management
Now since since 10 days he is having shortness of breath grade IV
Shortness of breath is also associated with vomitings on and off since 10 days (2 episodes per day for 3 days)
The vomitus was non bilious and non projectile and food particles as content
No history of fever, burning micturition and decreased urine output
Three sessions of dialysis was done from.the date of admission
Past history
Known case of Hypertension since 1 yr and is on medication
Personal history
Daily routine
The patient wakes up around 5 am and take breakfast around 9 am and lunch around 1pm and dinner around 8 pm and sleeps at 9 pm
Before 1 yr he used do daily labourer work and stopped since when he was diagnosed with chronic kidney disease
Diet : Mixed
Appetite Normal
Sleep adequate
Bowel and bladder Regular
Addictions occasionally
TREATMENT HISTORY : medication for hypertension
FAMILY HISTORY No significant family history
GENERAL EXAMINATION
Patient was conscious coherent and cooperative
Moderately built and nourished
Pallor present
Icterus absent
Cyanosis absent
Clubbing absent
Generalized lymphadenopathy absent
Bilateral pitting type of pedal edema present
Vitals:
Temperature Afebrile
Pulse rate 88bpm
Respiratory rate 17 cpm
Blood pressure 140/70 mm hg
GRBS 142 mg /dl
SYSTEMIC EXAMINATION
Respiratory System
Inspection
Symmetrical chest is seen
No scars and sinuses
Trachea is Central in position
Palpation:
Inspectory findings are confirmed
Expansion of chest is equal in all planes
Tactile vocal fremitus vibrations felt
Percussion:
Resonant note present over all lung areas
Auscultation:
Normal vesicular Breath sounds heard.
PER ABDOMEN
Inspection
No Abdominal distension
No scars, sinuses, mass visible
No engorged veins are seen
Umbilicus is central and inverted
No visible pulsations
Movements are equal over 9 regions during respiration
Palpation:
All inspectory findings are confirmed
No local rise of temperature
No Tenderness
No hepatomegaly and No spleenomegaly
Percussion
Resonant note heard
Auscultation
: Normal bowel sounds heard
No bruit heard
CARDIOVASCULAR SYSTEM EXAMINATION
Inspection : Bilaterally symmetrical chest present
No scars, sinuses
Palpation:
Inspectory findings are confirmed
Apex beat normal
On Auscultation :
S1 S2 heard
No murmurs or additional heart sounds heard
CENTRAL NERVOUS SYSTEM EXAMINATION
No focal neurological defecits
PROVISIONAL DIAGNOSIS
Chronic Renal Failure
INVESTIGATIONS
On 28/12/2022
On 29/12/2022
On 30/12/2022
ECG
TREATMENT
Inj LASIX 40 mg IV BD
Tab.NiCARDIA 20 mg PO/BD
Tab.ARKAMINE 0.1mg PO/BD
Fluid restriction to less than 1.5 lit per day
Salt restriction to less than 2 gm per day
Tab.Shelcal 500 mg PO/OD
Cap.BIOD3 PO/weekly once
Tab .OROFER PO/OD
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