Chronic Renal failure case

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A 82 year old male patient, resident of Choutuppal, came to casualty with chief complaints of shortness of breath since three months and chest pain, intermittent since 15 days. 

 History of present illness: Patient was apparently asymptomatic three months back then he developed exertional dyspnea associated with cough. Cough was productive. The sputum was wet. There is history of pedal oedema three months back which is is pitting type. There is history of chest pain, intermittent since 15 days. There is no history of fever, burning micturition, palpitations and decreased urine output. 

Past history: Patient is a known case of hypertension since 4 years. On medication-Tab. telmisartan 40mg. Patient is not a known case of diabetes,TB, CVD, bronchial asthma, thyroid disorders, epilepsy. 

Family history: No significant family history. 

Personal history: Diet is mixed, appetite is normal, sleep is adequate, bowel and bladder movements are regular. Micturition is normal. No known allergies. Stoppage of alcohol and smoking since five years. 

Drug history: on telmisartan 40mg for hypertension. 

General examination

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

There is pallor and oedema of feet. No icterus, cyanosis, clubbing, lymphadenopathy

Vitals: BP: 150/80mmHg PR: 76beats/min.                      Afebrile. RR: 19cycles/min

Systemic examination 

CVS: S1,S2 +.     RS: normal breath sounds heard. 

CNS: NAD

Investigations















 Provisional diagnosis: Chronic Renal Failure

Management : On Dialysis. 









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