general Medicine

Ch Janani 
Roll no. 29
A 55 yr old female came to OPD with complaints of pedal edema,shortness of breath since 3 days and decrease urine output.

Cheif complaint
Pedal edema
Shortness of breath
Decrease urine output

History of present illness
Pedal edema and shortness of breath since 3 days and decreased urine output.


History of past illness
known case of diabetes since 10 yrs hypertension since 10 yrs 
Not known case of tb, epilepsy 

Family history
Family history of diabetes and hypertension

Personal history
Married
Loss of appetite
Diet: mixed
Bowel and bladder movements are abnormal
No allergies
No drug history

General examination
Moderately built
No palor
No cyanosis
No icterus
No lymphadenopathy
No clubbing
No pedal edema

Vitals
Temperature 98 F
Pulse rate 98/min
Bp 140/90mmHg
GRBS 100 %

Systemic examination
Cvs
S1 ans S2 are present
No thrills 
No murmurs

Respiratory system
No dyspnea and no wheezing
Position of trachea is central
Breath sounds are vesicular

Abdomen
No palpable mass
No tenderness
No bruits
No splenomegaly 
No hepatomegaly

CNS
Conscious and coherent
Sensory and motor system are normal

Provisional diagnosis
CKD on MHD
Investigations



Treatment
22/05/22
Tab LASIX 40 mg ×PO×BD 

Tab NODOSIS 500 mg× PO×BD 

Tab SHELCAL CT ×PO×OD 

Tab BIO - D3 0.25 mg× PO×OD 

Tab OROFER × 5×PO×OD

Cap bio D3 PO×OD

Inj ERYTHROPOIETIN weekly once 

Inj IRON SUCROSE weekly once 

7/06/22
Tab LASIX 40 mg ×PO×BD 

Tab NODOSIS 500 mg× PO×BD 

Tab SHELCAL CT ×PO×OD

Tab BIO - D3 0.25 mg× PO×OD 

Tab OROFER × 5×PO×OD

Cap bio D3 PO×OD

11/06/22

Tab LASIX 40 mg ×PO×BD 

Tab NODOSIS 500 mg× PO×BD 

Tab SHELCAL CT ×PO×OD 

Tab BIO - D3 0.25 mg× PO×OD 

Tab OROFER × 5×PO×OD

Cap bio D3 PO×OD





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