A 60 Years old Male patient with a cheif complaint of pedal edema, shortness of breath
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ECG
Chief complaints :
A 60 years old male Patient complaints of pedal edema since 2 years and shortness of breath since 2 months
History of present illness:
Patient was apparently asymptomatic 2 years back the he noticed pedal edema,shortness of breath since 2 months
No H/o fever,cold,cough
History of past illness:
History of hypertension since 1 year
Diabetes since 3 months
Personal History:
Diet - Mixed
Appetite - normal
Sleep - Adequate
Micturition - Normal
Bowel and bladder movements -Regular
Addictions - No addictions
Family History:
No significant family history
Drug history:
No allergic to drugs
General Examination
Patient was conscious, coherent, cooperative well oriented to time place and person
Moderately built and well nourished
No H/o cyanosis,icterus,lymphadenopathy
Clubbing of fingers
History of pallor pedal edema
Vitals
Temperature- afebrile
Pulse rate - 72 bpm
Respiratory rate- 16 cpm
Blood pressure - 150 /90mmhg
Systemic Examination
Abdomen
By taking consent from the patient examined in a well lited room
Inspection
Shape of the abdomen- Distended
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins
Palpation:
No local rise of temperature
No tenderness
No palpable mass
No organomegaly.
Percussion:
No Fluid thrill
No shifting dullness
Auscultation:
Bowel sounds are heard.
RESPIRATORY SYSTEM :
Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion
CVS :
S1&S2 heard
No murmurs
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
Motor system normal
Sensory system normal
Able to percieve-:pain , temp.
Cranial nerves : intact
INVESTIGATIONS
ECG
Diagnosis
CKD
Treatment
Tab.NODOSIS 500 mg po/BD
Tab.NICARDIA 20 mg po/ Tid
Cap.bio D3 po weekly once
Tab.SHELCAL 500 mg po/ od
Tab.REVALAMER 400 mg po/ od
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