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A 55 year old male patient presented to the opd on 8-11-21 with chief complaints of bilateral pedal edema since 10 days ,shortness of breath since 4 days , facial puffiness and decreased appetite since 2 days .
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years back and then he developed right sided hemiparesis and was diagnosed with CVA and was on antiplatelets.
2 years back he was also diagnosed with diabetes and hypertension.
Patient has pedal edema up to knee and sob since 1&1/2 hr and was diagnosed as ckd and he is on Medication.
In our hospital he was admitted on 8 November. After 5 dialysis facial puffiness decreased.
He has stiffness in his right leg for which he is unable to walk.
3 blood transfusion were done
11 sessions of dialysis were done .
The patient had blurred vision since 2 yrs.
PAST HISTORY
Patient is a known case of diabetes and hypertension since 2 years .
No history of asthma , tuberculosis.
PERSONAL HISTORY
Diet - mixed
Micturition - abnormal
Bowels - regular
Appetite - decreased
Alcohol - regular , stopped 3 years ago.
Sleep - inadequate
FAMILY HISTORY
No relevant family history.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
Edema is present.
No icterus,cyanosis, clubbing.
No lymphadenopathy
Vitals:
Temperature: afebrile
Pulse : 90bpm/min
Respiratory rate : 24/min
B p : 110/70mmhg
SpO2 : 98%
SYSTEMIC EXAMINATION
Bilateral airway+
Position of trachea - central
No dyspnea
CVS
No thrills
No murmers
Abdomen
Shape - scaphoid
No tenderness
Clinical images
Investigation
PROVISIONAL DIAGNOSIS
Chronic renal failure on MHD acute LVF (2° to hypertension) on chronic heart failure.
TREATMENT
1.FLUID RESTRICTION <1L/day
2.SALT RESTRICTION <2g/day
3.T.LASIX 40mg PO TID
4.T.PAN 40 mg PO OD
5. T.AMALONG 10 mg PO OD
6. T.ECOSPRIN AV PO OD
7.T. METXL 50 mg PO OD
8. T. HYDRALAZINE 12.5 mg
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