A 39 YRS OLD WITH CKD ON MHD
Chief complaints:
Patient c/o SOB since 3 months
HOPI :
Patient was apparently asymptomatic 1 year ago then he developed blurring of vision and was diagnosed with hypertension and CKD with hypertensive changes in the right eye since then he was on conservative therapy stayed in hospital for 5 days in ICU .
3 months patient developed SOB grade II-III and pitting type of pedal edema ( b/l )and significant weight loss
No H/o pyuria, palpitations, chest pain.
H/o orthopnea, PND
Then he underwent dialysis at NIMS punjagutta ( right IJV- 3 sessions)
HISTORY OF PAST ILLNESS:
k/c/o HTN since 1year
N/k/c/o DM, epilepsy, asthma, CAD, TB, CVA, thyroid disorder.
PREVIOUS HISTORY:
Appetite:normal
Diet:mixed
Bowel and bladder:regular
Sleep: adequate
No addictions
FAMILY HISTORY:
K/c/o HTN in the family
GENERAL EXAMINATION:
Patient is conscious and coherent
Moderately built and moderately nourished
Well oriented to time, place and person.
No pallor
No Icterus
No cyanosis
No clubbing
No lymphadenopathy
Pedal edema+
No malnutrition
No dehydration
VITALS:
Temperature-98.8F
Pulse rate- 96/min
Respiratory rate- 16 cycles/min
BP- 160/100mmHg
SPO2 - 98%
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM
BAE+
Dyspnoea:No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
ABDOMEN
Shape - Scaphoid
No tenderness, palpable mass,
No Fluid
No bruits
CENTRAL NERVOUS SYSTEM
Level of consciousness - consciouss
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
Tone-both upper and lower limbs normal
Power-upper limbs:4/5(both right and left)
Lower limbs:4/5(both right and left)
Reflexes : RIGHT LEFT
Biceps : ++ ++
Triceps : ++ ++
Supinator : ++ ++
Knee : ++ ++
Ankle : ++ ++
TREATMENT HISTORY:
TAB.TELMA 80mg/OD
TAB.NIFEDIPINE EXTENDED RELEASE 20mg/po/qid
TAB.TORSEMIDE 100mg/PO/OD
TAB.CLONIDINE 0.1mg/PO/TID
TAB.PRAZOSIN 2.5 mg /PO/BD
TAB.METOPROLOL 25mg/PO/BD
INVESTIGATIONS:
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