General medical case

 Chief complaint 


65year male from nalgonda presentzed to opd complaint of fever and legpain since one month


History of present illness 


Patient was apparently asymptomatic from past one month. On date 1/10/2021 patient taken to hospital with complaints of fever and pedal edema. Doctors told him elevated blood Urea and blood glucose and advised to undergo dialysis. 


​History of past illness 


Patient is not know case of hypertension 

Coronary artery disease, asthma, tb, any surgery. 

Personal history 

Diet mixed 

Sleep adquate

Appetite normal

Bowel and bladder regular 

addictions patient smokes occasionally consume alcohol occasionally 

Family history 

No history of similar complaint in family 

General examination 

Patient is conscious, coherent coperative

There is no icterus

Pallor is seen 

No cyanosis

no clubbing of toes and fingers 

No lymphadenopathy, no malnutrition 

Vitals

Temperature 98.2degree F

Pulse rate 98 bpm

Respiratory rate 24 cpm

Bp 140/90 mmbh

Spo2 98%

Random blood sugarSystemic examination 

Cvs

Trills not heard

No cardiac murmurs

Respiratory

Dyspnoea 

No wheezing

Position of trachea central

Breath sound vesicular

Abdomen

Shape of abdomen scaphold

No tenderness

No palpable mass

Normal herina orifices

No free fluid 

No bruits

Liver not palpable 

Bowel sound heard

Cns 

Level of consciousness alterted

Speech normal


​Treatment 

T. LASIX

T. PAN 40 mg/Po/BD

T. OROXT PO/BD

SALT RESTRICTION

FULID RESTRICTION

Ix



ECG

SERUM CREATININE



COMPLETE URINE EXAMINATION 

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