24th august 2020
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A 44 year old male patient presented to opd with chief complaints of pedal edema, shortness of breathe and facial puffiness since 1 month.
History of Present illness:
-Patient was apparently asymptomatic since one month back then develops pedal edema, shortness of breath and facial puffiness.
-Now visited the casuality due to fever and chills, dry cough since the day before and shortness of breath grade 3 and 4.
History of past illness:
-There is history of hypertension since 2years.
-There is history of covid 19 since 3months back and treated in home isolation.
-History of chronic kidney disease and on medical management and done the hemodialysis for 5 sessions from 1 month.
-There is no history of asthma, diabetes, tuberculosis.
Treatment history:
-Medication for hypertension was taken.(Nifedipine since 1 and half years).
-Blood transfusion.
Personal history:
Diet-Mixed.
Sleep-adequate.
Apetite-lost.
Bowel and bladder movements- Regular.
Addictions- Alcohol intake occasionally .
There is no history of allergies to known drugs.
Family history:
No history of such similar complaints in the family.
General examination
Patient was conscious, coherent and cooperative.
Well oriented to time, place and person.
-Physical examination:
Pallor- yes.
Icterus-No.
Cyanosis-No.
Clubbing-No.
Generalized lymphadenopathy-No.
Moderately built and norished.
Vitals:
-Temperature-102°F
-Pulse-104/min.
- Respiratory count-32/min.
-blood pressure-170/100mm of hg.
-spo2 at room air-98%
Systemic examination:
-Cardiovascular system-
Chest wall is bilateral symmetry.
S1 and S2 are heard.
-Respiratory system-
Bilateral airway
Dyspnoea is present
Position of trachea is central
Normal vesicular breath sounds are heard
-Abdomen-
Abdomen is soft and tender
Bowel sounds are heard
-Central nervous system-
Patient is conscious
Reflexes are normal
Speech is normal
Provisional diagnosis:
Chronic kidney disease on hepatic hemosiderosis in maintenance hemodialysis.
Investigations:
Liver function test:
Blood urea:
Treatment:
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