General medicine case-prefinal
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A 46 years old male patient ,presented to our OPD on 11 /12/2021 with the complaint of bilateral pedal edema ,generalised weakness, shortness of breath since 3 months .
History of present illness :-
-Patient was apparently asymptomatic 3 month back .
-Then patient developed bilateral pedal edema which is extending up to knee which is pitting type .
-Patient also has facial puffiness from 10 days , shortness of breath from 15 days .
Daily routine :-
-Patient was a tailor by occupation ,wake up daily at 6am ,have breakfast between 8 to 9 am ,then he start his work around 10am at home.
- Patient will have lunch around 1 to 2pm then he take some break for 30min to hr then again he start his work .
- Patient have the dinner at 8pm chapathi with some rice and go to bed at 10pm .
-Patient is undergoing dialysis since 3 months ,weekly twice .
-Patient completed 22 dialysis up to know .
Past history:-
-Patient was diabetic from 12 yrs .
-Patient has a history of hypertension from 3 yrs .
-No history of asthma, epilepsy .
- Patient had a history of nephrolithotomy
(Removal of kidney stones ) 15 yrs back .
-Patient has history of blood transfusion -4 times from last 2 months .
Personal history :-
-Diet :- mixed
-Appetite :- decreased
- Sleep :- normal
-Bowel and bladder movements :- normal
Decreased urine output from onset of dialysis . Constipation.
-Addictions :- Has a history of occasional alcohol intake , stopped 5yrs back .No history of smoking .
Family history :-
-Patient father has history of chronic kidney disease and died 11 yrs back .
Drug history :-
-No history of allergy to known drugs .
-Patient on medication for diabetes and hypertension .
General examination :-
-Patient is conscious , coherent, cooperative and well oriented to surroundings .
- Patient is moderately built and nourished.
-No clubbing, icterus, cyanosis, lymphadenopathy .
-Pallor - Present .
-Patient has pedal edema which is pitting type .
Vitals
-Temparature :- Afebrile
-BP. :- 130/90 mmHg
-Pulse rate :- 86 beats/min
-Respiratory rate :- 21 cycles /min
-SPO2 :- 98%
-GRBS :- 104 mg %
Systemic examination:-
- CVS :- Inspection :- Chest wall is bilaterally symetrical ,No visible pulsations or engorged veins .
Palpation:- JVP is normal .
Auscultation:- S1,S2 heard ,no murmurs .
-Respiratory system :- Bilateral air entry is normal.
-CNS :- Patient is conscious and well oriented to surroundings.
Speech is normal.
Investigations:-
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