A 38 yr old male came with c/c of SOB AND PEDAL EDEMA SINCE 2 MONTHS

 A 38 yr old male resident of suryapet farmer by occupation came with

CHIEF COMPLAINTS: Shortness of breath since 2 months

                                       Pedal edema since 2 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 yrs ago then he developed VOMITINGS which is non projectile,non bilious,3 episodes,copious in amount for 2 days relieved on medication not associated with fever,sweating,giddiness,syncope, headache

DIFFICULTY IN SWALLOWING associated with throbbing type of pain and halitosis for this he went to hospital there he was diagnosed as tonsillitis .After Using unknown medication for 1 year he had undergone tonsillectomy 2 years ago.During this he was diagnosed as hypertensive as his BP was 180/100 

He had an accident 2 years ago.Amputation of right leg below knee was done  and during this he came to know his serum creatinine was 5.6 and HB=6.2 (4 units of blood transfused thn HB= 9) 

After 2 months of resting he went to hospital n advised to have renal biopsy.They concluded that his 60%  of  kidney has damaged so he used unknown medication for 1and half year

He went to hospital with c/c SOB which is insidious in onset gradually progressive from Grade 3 to grade 4 associated with Pitting type of pedal edema grade 4 above ankle joint since 2 months.His sr.creat was 11 so he underwent hemodialysis for 5 times (NIMS)

He underwent hemodialysis for 10 times  here

PAST HISTORY: K/C/O HTN for 2yrs on medication ARKAMINE N CLINIDIPINE

NO H/O DM ,ASTHMA, EPILEPSY,THYROID

FAMILY HISTORY : Not significant 

PERSONAL HISTORY:

DIET:mixed

Appetite : Normal

SLEEP: adequate

BOWEL AND BLADDER MOVEMENTS: REGULAR

ADDICTIONS : NO

GENERAL PHYSICAL EXAMINATION :

Patient is conscious, coherent, cooperative.Well oriented to time place person.Moderately built,moderalety nourished.

Pallor: present 

Icterus:absent

Clubbing:absent

Cyanosis:absent

Pedal edema:absent

Lymphadenopathy: absent

VITALS:

BP:120/80

PR:75bpm

RR:20cpm

TEMP: afebrile 


SYSTEMIC EXAMINATION:

NO FINDINGS IN CVS,CNS,RS, ABDOMEN

PROVISIONAL DIAGNOSIS:

CKD ON MHD

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