A 75 year old man with pedal edema,loss of appetite,Nausea and Vomiting

Chief complaints:

70 year old male resident of muppara Came to the opd with complaint of restlessness; vomiting and loss of appetite 

HOPI

Patient is apparently asymptomatic 4 years back then he developed decreased urine output and was diagnosed with CKD and was on medication 

15 days back he collapsed while walking and taken to RMP his BP then was 220mmhg and pulse was 50 beats per minute

Then he was taken to a private hospital in suryapet and was given a injection?

DAILY ROUTINE:

 He wakes up at 6 AM and freshens up. He has breakfast at around 9 am and then rests for some time. He has lunch at 1 pm and rests for an hour. In the evenings he spends time with his family or by himself or chats with the neighbors. He takes dinner at 8 pm and goes to bed. 

PAST HISTORY:

Pt is a K/C/O HTN since 25yrs and DM2 since 8yrs

Pt is not a K/C/O TB,asthma, epilepsy,thyroid disorders.


PERSONAL HISTORY: 

Diet-Mixed

Appetite-Normal

B and B movements- Regular

Sleep- Regular

No addictions

TREATMENT HISTORY: pt is on antihypertensives and Oral hyperglycemic agents.

FAMILY AND ALLERGIC HISTORY: No relevant history 


GENERAL EXAMINATION: 

Patient was conscious, cooperative,well oriented to time,place , person.Moderately nourished and well built

PALLOR WAS PRESENT

NO CYANOSIS

NO ICTERUS

NO CLUBBING

NO GENERALISED LYMPHADENOPATHY

PEDAL EDEMA PRESENT (Pitting type)

VITALS::

TEMP AFEBRILE

PR 88 bpm

RR 14cpm

BP 

Systemic Examination:

Abdomen: Soft and non tender. Bowel sounds heard 

Cardiovascular system: S1,S2 heard 

Central nervous system: No focal neurological deficits.

Respiratory system: Bilateral Air entry present. NVBS 

 Breath sounds heard all over the chest. Trachea is Central .

INVESTIGATIONS:


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