A 45 years old male patient with pedal edema and SOB
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Chief complaints
A 45 year old male came to casualty with a complaint of pedal edema and SOB
History of present illness
A 45 year old patient who is security by occupation was apparently asymptomatic one week back then he developed pedal edema with Decreased urine output and SOB gradually progressed increased on exertion
First he went to private hospital and undergone dialysis four times
History of past illness
He was diagnosed with HTN for which he ordered renal function tests 3 years ago where his renal parameters has been damaged. He was Conservative treatment for about 3 years
N/k/c/o Dm,Asthma, Epilepsy ,Tb
K/c/o Hypertension (3years), anemia.
Personal History
Status- Married
Appetite- Normal
Diet-Mixed
Allergies- No
Sleep-Adequate
Bowel movements-Regular
Micturition - Normal
Addiction- Alcohol occasionally
Family History
Patient father has diabetes, Hypertension
General Examination
Patient is conscious, coherent cooperative
No history of cyanosis, clubbing lymphadenopathy, pallor
Physical status-Moderately built
Vitals
Temp-98.3F
PR-78
RR-18
BP-130/90
Systemic Examination
Cvs-cardiac sound : S1,S2+
No thrills Cardiac murmurs
Respiratory system
Dyspnoea-No
Wheeze-No
Abdomen Shape-Scaphoid
Diagnoses
Chronic Renal failure
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