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.