General medicine case-5
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Chief complaint:
A 55- year old male presented to the OPD with chief complaint of shortness of breath since 2 days.
History of present illness:
Patient was apparently asymptomatic 2 months back then developed pedal edema- pitting type grade-1 then gradually progressed to grade-2 over 10 days and to grade-3 over 15 days.
Past history:
The patient has a history of pulmonary koch's 21 years back and had ATT for 6 months.
Known case of hypertension.
No history of asthma, diabetes, epilepsy.
Personal history:
The patient has a mixed diet.
Appetite is normal.
Has adeequate sleep.
Bowel and bladder movements normal.
No history of smoking and alcohol consumption.
Family history:
No similar complaints in the family.
General Examination :
Patient is conscious, coherent and cooperative
Moderately built
Pallor is present
No cyanosis,clubbing,icterus,lymphadenopathy
Pitting type of pedal edema is present.
Vitals:
Temperature: afebrile
Pulse rate: 120 BPM
Respiration rate: 16 cycles per min
BP: 160/80 mm/Hg.
Systemic examination:
CVS:
No thrills
S1 S2 +
No murmurs heard.
Respiratory system:
Dyspnoea present.
Expiratory wheeze is present in all areas
Position of trachea: central
Breath sounds: vesicular
Abdomen:
Shape of abdomen: distended
No tenderness
No palpable mass
Hernial orifice: normal
Free fluid is present
No bruits
Liver: not palpable
Spleen: not palpable
Bowel sounds are heard
CNS:
Patient is conscious
Speech is present
Reflexes are normal
Investigations:
Final diagnosis:
Nephrotic syndrome.
Treatment:
1) FLUID RESTRICTION <1 L/ DAY
2)SALT RESTRICTION <2g/ day
3)TAB LASIX 40 mg
4)TAB RAMIPRIL 5 mg PO/BD
5) TAB PAN-D PO/OD
6) TAB NODOSIS 500mg PO/BD
7) MONITOR WT AND Abd
GIRTH- DAILY
8) I/O CHARTING
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