1 December  2022

CHIEF COMPLAINT

A 40 yrs old female patient came to the opd with chief complaints of swelling of foot since one year and puffiness of face since 2 months

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic one year back then  she developed bilateral pedal edema extending upto the knee, putting type. Puffiness of face since 2 months back and reduced puffiness of face after taking medication after one week

HISTORY OF PAST ILLNESSES

K/C/O Hypertension since 3 years and she was on medication- T -NICARDIA 20mg po bd

K/C/O Hypothyroidism since 1year and she was on medication- Thyroxin 50mcg po od

N/K/C/I diabetes Mellitus TB asthma epilepsy

PERSONAL HISTORY 

Married

Occupation- home maker

Appite- normal

Diet - mixed

Bowel movements- normal

Micturation- normal

Drug allergies- no known drug allergy

Habits  / addiction - no habits

FAMILY HISTORY

Not significant

MENSTRUAL HISTORY

Normal 

HISTERIC HISTORY

2 children

1 abortion

PHYSICAL EXAMINATION

GENERAL

Patient is examined under well lit room and adequate ventilation with her consent taken. 

Patient is conscious coherent and cooperative

Well oriented to time place and person

Pallor- yes

Cyanosis - no

Lymphadenopathy - no

Icterus- no

Malnutrition - no

Clubbing of fingers and toes - no

VITALS

temperature - 98.9 F

Pulse rate- 99 bpm

Bp - 130/90 mmhg

Spo2- 100%

Respiratory rate- 20 cycles per min

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Cardiac sounds -s1 s2 positive

RESPIRATORY SYSTEM

Dyspnoea - no

Wheeze - no

Position of Trachea - central

Breath sounds- vestibular

ABDOMEN

Shape of the abdomen - Scaphoid 

No tenderness

No palpable mass 

Liver - not palpable

Spleen- not palpable

Bowel sounds - yes

CENTRAL NERVOUS SYSTEM

Level of consciousness - conscious / alert

Speech - normal

Sign of Meningeal irritation

      Neck stiffness- no

      Kemings sign - no

PROVISIONAL DIAGNOSIS

CHRONIC RENAL FAILURE

INVESTIGATION











TREATMENT

Nicardia 20mg PO BD

Tab Nodosis 500 mg PO BD

Tab Lasix 40mg PO BD

Injection Erythropoietin 4000 IU s/c weekly once

Tab dolo 650mg  PO QID

Vitals monitoring 4th hourly
























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