A 65 year old male with abdominal distention,urinary retention
Short case
Name:N.vishnu rohith Reddy
Hall ticket no:1701006126
June 11th 2022
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Pedal edema for 2days
Abdominal distention for 2 days
Shortness of breath for 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 months back,then he developed swelling of legs for which he went to a hospital in nakrekal where he was diagnosed with renal calculi.he was treated conservatively for that.
Then 1 month back he went to the same hospital for similar complaints of pedal edema for which he was referred to our hospital.He was treated conservatively for that l. Then 2 days back he came to hospital with complaints of pedal edema which was insidious in onset gradually progressive from grade 1 to grade 2,there is no decrease in edema with overnight rest,associated with facial puffiness.
Then 2 days back patient complained of abdominal distention which was insidious in onset gradually progressive,no aggregating factors and not relieved on rest.
Then he developed shortness of breath which was insidious in onset gradually progressive in nature aggregated on doing work and relieved on rest. It is not associated with cough,fever,hemoptysis,chest pain.
PAST HISTORY
He had right sided indirect inguinal hernia for which hernioraphy was done 13 years back.
He is known case hypertension since 4 years and he is on medication since 4 years
No history of diabetes,asthma,tb,cad,stroke
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:urinary retention
Addictions:regular alcoholic
FAMILY HISTORY:
family member has hypertension
No history of diabetes,asthma,tb,cad,stroke.
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:82b/m
Respiratory rate:22c/m
BP:140/70mmhg
Spo2:99
Grbs:134mg%
Pallor: present
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:present
SYSTEMIC EXAMINATION:
Shape:distended
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
No Tenderness
No local rise of temperature
DEEP PALPATION:
liver:palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
Liver span:14cm
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CARDIOVASCULAR SYSTEM:
S1,S2 Heard
no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact
PROVISIONAL DOAGNOSIS:
Acute exacerbation of chronic renal failure
Tab nodosis-500mg bd
Inj metrogel-500mg tid
Tab pan- 40mg of
Oroferxt- of
Tab shelcal-od
Tab nicardipine-20mg bd
