Case history-5
4/10/21
Date of admission:27/9/21
A 45yr old male presented to the opd with the chief complaint of B/L pedal edema since 1 year and SOB(grade 3-4)since 4days and decrease in urine output since 1 week .
HISTORY OF PRESENT ILLNESS:Patient was apparently asymptomatic 1 year back ,then he developed bilateral pedal edema ,which is gradual ,pitting type ,progressive in nature ,extended up to knee ,aggravated on walking .c/o sob grade (3-4)-progressive .no c/o orthopnea ,PND ,burning micturation .
HISTORY OF PAST ILLNESS:
K/c/o HTN since 12 yrs and on tab.Amlong 5 mg (11yr) &tab .nicardia 20mg (2yr)not a k/c/o DM/TB/CAD/ASTHMA /epilepsy.
PERSONAL HISTORY:
Married ,normal appetite,non vegetarian,regular bowel movement,micturation normal ,no known allergies,no addictions .
FAMILY HISTORY:
No history of diabetes, hypertension,heart disease, stroke, asthma, tuberculosis,cancers.
GENERAL EXAMINATION:
The patient is conscious, coherent, cooperative.
No Palar
No icterus
No cyanosis
No clubbing
No dehydration
No lymphadenopathy
No malnutrition
Edema -present
VITALS :
Temp :afebrile
Pulse rate :11.8/min
Bp :160/90 mm/hg
Respiratory rate :19cpm
SYSTEMIC EXAMINATION:
CVS:
No thrills
Cardiac sounds :s1,s2 heard
No cardiac murmurs
RESPIRATORY SYSTEM :
No dysponea
No wheeze
Position of trachea :central
Breath sounds :vesicular
ABDOMEN :
Shape of abdomen:scaphoid
Tenderness:diffuse
No palpable mass
Hernial orifices -normal
No free fluid
No bruits
Liver ,spleen -not palpable
Bowel sounds -yes
CNS :
Conscious
Normal speech
No neck stiffness
No kernings signs
CEREBRAL SIGNS:
Finger -nose in -coordination-yes
Knee-heel in-coordination-yes
INVESTIGATIONS:
27/9/21
Dept of pathology:
Dept of biochemistry:
Dept of microbiology:
ECG REPORT:
29/9/21
Dept of pathology:
Dept of biochemistry:
2/10/21
Dept of pathology :
4/10/21
Provisional diagnosis:CKD ON MHD with respect to bilateral hearing loss
Final diagnosis:CKD ON MHD .
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