GENERAL MEDICINE CASE 6
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0ctober 18,2021
60 years old male patient came to the casualty with chief complaint of pedal edema since 2year and shortness of breath since 1year worsening since 1week .
HISTORY OF PRESENT ILLNESS
The patient is asymptomatic 25years ago and he was diagnosed to be diabetic as he has history of loss of consciousness.And he is on irregular medication for 10-12yrs,and using regularly since 8yrs.
History of pedal edema 2yrs back
Paitent has shortness of breath since 1yr and worsening since 1week
History of chest pain.
history of CAD in jan and diagnosed to be having MI.
PAST HISTORY
The patient is known case of hypertension and diabetics
No history of trauma
PERSONAL HISTORY
Appetite is noemal
mixed diet
Sleep adequate
Bowel and bladder movements normal
History of alocholic habit before 10yrs
TREATMENT HISTORY
No history of drug allergy
FAMILY HISTORY
No similar complaints in the family
GENERAL PHYSICAL EXAMINATION
Patient is conscious ,coherent and co-operative
no icterus,cyanosis and clubbing.
edema of feet is present
VITALS
Temp:98.4°C
PR:84bpm
RR:20/min
BP:140/90 mmHg
spO2:96%
GRBS:190mg%
SYSTEMIC EXAMINATION:
CVS:
No thrills
S1 , S2 heard
No cardiac murmurs
RESPIRATORY SYSTEM:
Dyspnoea - present on exertion
No wheezing
Position of trachea:central
Breath sounds-vesicular
ABDOMEN:
Shape of abdomen-scaphoid
No tenderness
No palpation
No bruits
Liver - not palpable
Spleen - not palpable
Bowel sounds are present
CNS:
No abnormality detected.
INVESTIGATION
RFT
UREA-108mg/dl
CREATININE-6.3mg/dl
URIC ACID-3.8mg/dl
CALCIUM-7.5mg/dl
PHOSPHOROUS-4.2mg/dl
SODIUM-139MEqL
POTASSIUM-4.3MEqL
CHLORIDE-99MEqL
LIVER FUNCTION TEST
Total Bilurubin-0.77mg/dl
Direct Bilurubin-0.18mg/dl
SGOT-24IU/L
SGPT-11IU/L
ALKALINE PHOSPHATE-225IU/L
TOTAL PROTIENS-6.0gm/dl
ALBUMIN-3.3gm/dl
A/G RATIO-1.23
ECG
PROVISIONAL DIAGNOSIS-acute kidney disease with MI
TREATMENT
1.Fluid restriction <1.5L/day
2.Salt restriction <2gm/day
3.Tab Lasix 40mg PO/BD
4.Tab eosprin-AV PO/BD
5.Tab amlong 5mg PO/OD
6.Tab tamsulosin 4mg PO/OD
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