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A 65 yr old female Home maker by occupation resident of Vangamarthi was presented to the OPD with chief complaints of :
Pedal oedema since 10 days
decreased urine output since one week
On and off fever since one week
Shortness of breath since two days
HISTORY OF PRESENTING ILLNESS
the patient was apparently asymptomatic four years ago when she developed prolapsed uterus for which she underwent hysterectomy And then she developed high grade fever. She was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.
She has been taking NSA IDs for joint pain since four years
The patient complains of shortness of breath which is of grade 2
History of past illness:
The patient was advised for some surgery? DJ stenting but patient denied it and is on conservative treatment.
No history of hypertension
No history of DM
No history of thyroid
Personal history
Appetite normal
Diet mixed
Bowl and ladder moments regular
No known allergies
Consumes alcohol occasionally
No history of smoking
Family history
No significant family history
Examination
General examination
Patient is conscious coherent and cooperative
Patient moderately built and nourished
No pallor
No cyanosis
No lymphadenopathy
No icterus
No clubbing
Vitals
Temperature 98.6° F
PR 98bpm
RR 18 per minute
BP 110/80 mmHg
Systemic examination
CVS
S1 S2 heard
No murmurs
RESPIRATORY SYSTEM
Position of trachea central
BAE +
No audible wheeze
Abdomen
Soft, non-tender
Liver spleen not palpable
INVESTIGATIONS
PROVISIONAL DIAGNOSIS:
Chronic renal failure
TREATMENT:
DATE: 7/6/2022
Tab Lasix 40mg /PO/BD
Tab nodosis 500mg /Po/BD
Inj epo 5000 IU/SC /once weekly
Inj iron sucrose 1 AMP in 100ml NS /OD
Tab shelcal 500mg /PO/OD
Tab orofer xt /PO / OD
DATE: 8/6/2022
Tab Lasix 40mg /PO/BD
Tab nodosis 500mg /Po/BD
Inj epo 5000 IU/SC /once weekly
Inj iron sucrose 1 AMP in 100ml NS /OD
Tab shelcal 500mg /PO/OD
Tab orofer xt /PO / OD
Tab pan 40mg/PO/BD
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