GM case presentation 2
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A 46 yr old female came to the casualty with the chief complaint of bilateral pedal edema , fever with chills and decreased urine output since 20 days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic till June 2021 , then she developed fever, shortness of breath, vomitings and pedal edema since 3 days. Then she visited a local hospital in nalgonda and done 2 hemodialysis there . Then she went to NIMS hospital , and came to our hospital , 9 hemodialysis were done in the hospital . But now she complaints of edema of right lower limb and fever with chills and decreased urine output since 20 days.
PAST HISTORY:
No history of HTN , Asthma , Epilepsy, Tb.
History of diabetes mellitus since 3 yrs.
Pt has undergone eye surgery 2 yrs back.
TREATMENT HISTORY:
Pt is on medication for diabetes mellitus
No history of allergies to any known drugs.
History of blood transfusion during dialysis.
FAMILY HISTORY:
No similar complaints in any of the family members .
No history of any sudden or cancer deaths in the family .
PERSONAL HISTORY:
Patient takes mixed diet , has normal apetite, bowel movements are normal but bladder movements are irregular.
No habit of drinking alcohol or smoking.
GENERAL EXAMINATION :
Pt is conscious , coherent and cooperative , well oriented to time place and person and examined in a well lit room in supine position. Pt is moderately built and nourished .
Pallor and edema of feet is present .
No icterus , no cyanosis , no clubbing , no lymphadenopathy.
Vitals :
Temperature -98.2 ° F
Pulse rate -92 beats per minute
Respiratory rate- 18 cycles per minute
Blood pressure - 130/ 100.
SYSTEMIC EXAMINATION :
CVS -
No thrill palpable.
S1 and S2 are heard.
No cardiac murmurs.
RESPIRATORY SYSTEM-
No dyspnea.
No wheezing sounds heard.
Position of trachea is central.
CNS -
Pt is conscious .
Speech is normal.
No neurological deficits.
PROVISIONAL DIAGNOSIS:
Chronic renal failure on dialysis.
Known case of type 2 diabetes mellitus .
INVESTIGATIONS :
Hemogram :
TREATMENT :
Fluid and salt restriction
Inj. Augmentin 1.2 mg IV BD
Tab pantop 40 mg OD
Tab nodosis 500 mg PO / OD
Tab Orofer XT PO / BD
Tab Nicardia 10 mg PO/ BD
Tab Shelcal 500mg PO / OD
Tab Dolo 650 mg TID
Inj . Neomol 100 ml IV .
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