A 90 Year Old Female with chief complaints of bilateral pedal edema since since 10 days.

 CHEIF COMPLAINTS 

Fever since 10 days 

Decreased apettite since 10days 

B/L Pedal Edema 

Decreased urinary output since one week

Vomitings 5 days back.

Chest pain 1 day back.

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 10 days back then she had c/o B/L Pedal Edema pitting type ,c/o fever ,chills intermittent,and no evening rise in temperature.she also had c/o decreased urine output and decreased apettite since 10 days .she has complaints of vomitings 3 episodes 5 days back,which was non-bilious,non-projectile,containing food particles resolved after taking medications.

PAST HISTORY: 


K/C/O HTN-since 2 yrs 

No H/O DM,TB 

TREATMENT HISTORY:

T.Atenolol 50 mg 

T.Amlodipine 5 mg 

No surgical history

PERSONAL HISTORY :

Appetite: decreased

Non vegetarian

Sleep : adequate

No addictions

FAMILY HISTORY:

-No significance

PHYSICAL EXAMINATION:

GENERAL EXAMINATION :

.pallor





.no icterus,cyanosis,clubbing, lymphadenopathy.

.B/L Pedal Edema pitting type


Pulse rate - 64/min

Temparature -afebrile

Respiratory rate -22/min

B.P-110/60

SYSTEMIC EXAMINATION :

CVS

• S1,S2 are heard 

• No thrills

• No cardiac murmurs

RESPIRATORY SYSTEM 

• No  dyspnoea 

• No wheeze

• Vesicular breath sounds

ABDOMEN 

• Scaphoid shaped abdomen

• No tenderness

• No palpable mass

Liver not palpable 

Spleen not palpable

CNS 

. Consciouss 

.Speech -normal

.No neck stuffiness 

.Motor and sensory system are normal

.cranial nerves normal

INVESTIGATIONS

.Hemogram,Renal function test,ECG,USG abdomen,chest x-ray.

  

Hb:6.1

PCV:19.2

TLC:9,400

RBC: 2.08

Platelet count:2.69

Blood urea: 2.14

Serum creatinine :10.0

S.Na+:126

S.K+:5.8

S.Cl-:89

PROVISIONAL DIAGNOSIS

Chronic renal failure 


TREATMENT 

INJ. PAN 40MG IV /STAT


4 INJ ZOFER 4MG / IV/STAT


Inj.LASTX 40 MG IV /BD


 TAB NODOCÊS 500mG PO/-BD


12 TAB ORO FER-XT | PO/OD


TAB SHELLAZ 500 mg


CAP BRO D3


po/ weakly once.


 TAB NEPHROSAVE PO/OD


SYP ARE STORYNE 


TAB LOBUN FORTC


NEBULISATION -SALBUTAMOL.






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