75 year old male who is farmer by occupation came to the OPD with the chief complaints of pedal edema and facial puffiness since 3days 

HISTORY OF PRESENT ILLNESS


The Patient was apparently asymptomatic 3 months back then he had fever first which didn't subside even after 4 days. He then experienced shortness of breath while still having fever. 


He went to a local doctor, symptoms did not subside and then came to our OPD where he was diagnosed with CKD and hypertension 

He used to have acidity from past 3 years occasionally for which he used to have antacids.

He also had a slight pain in the lower part of the abdomen

From the past five days, whatever he is eating is being vomited out which is non bilious, has no prior nauseous feeling, no vertigo, no blood, the content is which he eats at that time only, he is vomiting the undigested food. He is not even passing stools.

HISTORY OF PAST ILLNESS:

The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma

PERSONAL HISTORY:

-The patient has lost appetite 

-abnormal micturation

-no sleep disturbances 

FAMILY HISTORY:

There are no similar complaints in the family members

TREATMENT HISTORY:

The patient is not a known case of drug allergy

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

VITALS - temperature:98.4F

-pulse rate:86bpm

-respiration rate:18/min

-bp:110/70

-spo2-98%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM 

- Position of trachea  central Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- bowel and bladder sounds heard

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

INVESTIGATION


 










TREATMENT:


T.Nicardia 10mg BD 
T.Nodosis 500mg OD 
T.shelcal 500mg OD 
T.Lasit 40mg BD 
T. Orofer lasix BD

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