55 years old male c/o pedal edema, burning micturition
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Chief Complaints:
C/O Fever since 10days, Burning micturition since 10days, vomitings since 10days (5-6 episodes),Grade 3 SOB since 10days
History of Present Illness:
Patient is apparently asymptomatic 10days back then she noticed fever low grade,continuous type not associated with chills and rigors
H/o vomiting non projectile,non bilious,food as content
C/o SOB Grade 3 since 3days
C/o burning micturition after foleys insertion at local hospital
History of Past illness:
H/o hypertension since 2months (on regular medication)
No h/o DM,Asthma, epilepsy,TB,CAD
Personal History:
Married
Occupation: daily wage labour
Diet:mixed
Appetite:normal
Bowel movements: regular
No drug allergy
Family History:
No h/o DM, Asthma, Hypertension,TB,CAD, Epilepsy in the family
Menstrual history:
Menopause:20years back
General Examination:
Vitals:
Temp: Afibrile
Respiratory rate:24bpm
Pulse:86bpm
Blood pressure:130/90mmhg
Sp O2:96
Systemic Examination:
Cardiovascular Examination:
Thrills:No
Cardiac sounds:S1,S2 sounds
Cardiac murmurs:No
Respiratory system:
Position of trachea:central
Breath sounds: vesicular
Adventitious sounds:no
Wheeze:no
Dysponea:no
Abdomen
Shape of abdomen: scaphoid
Tenderness:not tender
Palpable mass:no
Henias orifices: normal
Free fluid:no
Bruits:yes
Liver:not palpable
Spleen:not palpable
Bowel sounds:yes
Central Nervous system:
Pt is conscious
Speech: normal
Signs of meningitis:no
Cranial nerves: normal
Motor and sensory system:normal
Provisional Diagnosis:
CRF
Investigation:
Treatment:
Tab.NICARDIA 10mg PO BD
Tab.NODOSIS 50Pmg PO BD
Tab.LASIX 40mg PO BD
Tab.OROFEX XT PO OD
Tab.SHELCAL PO OD
Inj.ERYTHROPOITEIN IV Weekly
