General medicine case 2
Date of admission:15/08/2021
Cheif complaint:
A 50 years old women who is a daily wage worker came to causality with cheif complaint of sob since 3months,pedal edema and decreased urine output since one year
History of present illnesses:
Patient was apparently asymptomatic 1year back then developed pedal edema which was gradually progressive and associated with sob with decreased urine out put.
Past history:
No similar complaints in the past .
No diabetes.
Hypertension is present
No asthma
No TB
No blood transfusions
No history of surgery in past
No epilepsy
Personal history:
Diet:abnormal
Appetite:normal
Bowel :regular
Bladder: irregular
No addictions.
Family history:
No history of similar compalinents in family
Drug history
No allergy to known drugs
General examination:-
Patient is conscious, cooperative and coherent
Pallor is present
No cyanosis
No lymphadenopathy
No dehydration
No clubbing of fingers
Vitals:
Temperature:98°f
Bp:140/90
Pulse rate:100/min
Respiratory rate:22/min
Systemic examination:-
Cvs
S1 and S2 sounds are heard.
Respiratory system:
Position of trachea:central
No dysponea
Breath sounds:vesicular
Abdomen:
Abdomen is scaphoid,tenderness is not present, no palpable mass is present.
CNS:
Patient is conscious
Speech is normal
No neck stiffness
Provisional diagnosis:
Ckd on mhd
Investigations:
Blood urea--117mg/dl
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