General medicine case 7

 

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A 55 year old male who cuts the stone by occupatiom came to causality with chief complaints of pedal edema, facial puffiness and shortness of breath since 2 months and cough since 3 months.  

History of present illness: 

Patient was apparently asymptomatic 5 to 6 months back then he had traumatic eye injury ( right eye ) ,while he was cutting granite stone due to which he had lost his vision .

 3 months back he developed cough occasionally which is wet type of cough .

2 months back he developed pedal edema which is non pitting type .he developed shortness of breath suddenly while doing work ,aggravated by doing work ,not reilived by taking medication . 

Daily routine : 

He wakes early in the morning by 5:00am , drinks tea then he used to go to his working place by bike between 7 to 10 am . By 1:00 pm he used to have his lunch, By 2:00 pm he used to go home . In between 8:00 to 9:00 pm he used to have his dinner . By 10:00 or 11:00 pm he used to go for sleep .

Past History : 

Hypertension 4 days back 

No history of diabetes mellitus 

No history of epilepsy ,asthma , tuberculosis 

Personal history: 

Apetite : reduced 

Sleep : adequate

Bowel and bladder movements : Normal

Diet : mixed 

Urine output : Normal with burning micturation 

Alcohol : weekly twice or thrice since 30 years 

Smoking : 2 to 3 times in a day ( BD ) since 30 years 

Family history :

 No similar history in the family 

General examination: 

Patient is conscious and coherent and well built 

 Temperature: afebrile 

Pulse rate : 72bpm 

Respiratory rate : 20 cycles per min 

BP : 140/70 mmhg 

SPO2 : 99 % 

No cyanosis

No icterus 

Systemic examination: 

CVS : S1 S2 heard 

Provisional diagnosis: 

CRF 

polycystic kidney disease 

Treatment: 

21/11 /21 

Fluid and salt restriction

T. NICARDIA 20mg BD 

T. NODOSIS 500mg BD 

T. OROFER XT PO BD 

Inj . Erythropoietin 4000 IU weekly once 

Tab . SHELCAL PO OD 

22/11/21 

Fluid and salt restriction

T. NICARDIA 20mg BD 

T. NODOSIS 500mg BD 

T. OROFER XT PO BD 

Inj . Erythropoietin 4000 IU weekly once 

Tab . SHELCAL PO OD 

24/11/21 

Temp: 98.4F 

BP : 130 /90 mm hg 

PR : 86bpm 

CVS : S1 S2 HEARD 

Fluid and salt restriction

T. NICARDIA 20mg BD 

T. NODOSIS 500mg BD 

T. OROFER XT PO BD 

Inj . Erythropoietin 4000 IU weekly once 

Tab . SHELCAL PO OD 

Inj. Thiamine NS 100mg in 50ml IV TID