1601006106 SHORT CASE

FINAL EXAM SHORT CASE :

A 56 yr old male patient resident of Aganmothkur,who is a farmer ,came to the hospital with chief complaints of shortness of breath since 1 day.

Patient was apparently asymptomatic 3 months back.Then he developed bilateral pedal edema of grade-4 pitting type and shortness of breath grade-3 for which he was hospitalised and was diagnosed to have Chronic kidney disease .Since then he had 11 sessions of hemodialysis .The last one was done as he had shortness of breath of grade-3 and bilateral pedal odema grade -3 pitting type .


Past history:He went to hospital as he had fever and was diagnosed to have Hypertension 5 months back .

Underwent surgery for intestinal perforation 2 yrs ago.


GENERAL EXAMINATION: The patient is conscious, coherent, coperative .Moderately built and nourished.

Pallor present

Icterus present. 

Bilateral pedal odema -pitting type-grade 3




No cyanosis, No clubbing, No koilonychia,No lymphadenopathy.

Incisional hernia above the umbilicus



Vitals:

Patient is afebrile

Pulse : 90 beats/min

Respiratory rate : 20 cycles / min

BP : 140/90 mm hg

CNS examination: 

Higher mental functions-normal 

Cranial nerves- intact

Sensory system- normal

Motor system- normal 

Meningeal signs- absent 

Cerebellar signs- absent

CARDIOVASCULAR SYSTEM

Apex beat: 5th intercostal space lateral to midclavicular line 

S1 and s2 heard 

JVP normal


RESPIRATORY SYSTEM

Breath sounds: normal 

No additional breath sounds 

☆Management:

Hemodialysis:through Central Venous Catheter.


Drugs:

Tab.lasix 40mg bd

Tab.nicardia 10mg tid

Tab.Arkamin 0.1mg tid

Tab.shelcal 500 mg od





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