63 year old male with pedal edema ,Shortness of breath and decreased urine output

February 3 2022

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February 3 2022

A 63 year old male came with 

Complaints of pedal edema 

                          Shortness of breath

                           Decreased urine output

Since 6 months.

HOPI

 Patient was apparently asymptomatic 6 months back later he developed pedal edema which is gradually progressive , pitting type which is gradually progressive. Shortness of breath , which is grade 2. Relived on rest. There is decreased urine output.

Then he went to NIMS hospital in Hyderabad. On investigations, he was diagnosed as chronic kidney disease.

He went dialysis there for 20 times.

PAST HISTORY 

He has diabetes mellitus since 16 years.

No history of hypertension, Tuberculosis, Epilepsy, asthma, thyroid abnormalities.

He had a trauma to left leg ( thorn prick) then he developed infection associated with pain. Then his toe and 2nd finger was excised. 

FAMILY HISTORY 

No significant family history.

PERSONAL HISTORY 

Diet : mixed.

Occupation: farmer.

Appetite: Normal.

Bowel and Bladder movements: regular.

Allergies: No 

Addiction:

     GENERAL EXAMINATION

Pallor: present

 

Icterus: absent 

Cyanosis: Absent 

Clubbing: absent 

Lymphadenopathy: absent 

Edema: pedal edema ( pitting type)

VITALS 

Temperature: Afebrile.

Pulse rate: 82 beats/ min 

Respiratory rate: 14 cycles/ min 

BP: 140/90 mm/ Hg 

Saturated Po2 : 99%

       SYSTEMIC EXAMINATION 

Cardio vascular system: S1,S2 heard, No murmurs heard.

Respiratory system : 

Dyspnea - present 

Breath sounds - Normal vesicular breath sounds.

Central nervous system: 

Patient is conscious, coherent , cooperative well oriented with time and place .

Speech - Normal 

No slurred speech.

No abnormality 

Gait - Normal 

Reflexes - ++

Abdominal cavity: soft, Non tender, No organomegaly 

     INVESTIGATIONS

USG 

Impressions 

Bilateral grade 1 RPD 

Mild ascites

Left mild pleural effusion. 

     LAB INVESTIGATIONS 

  Serology: HBsAg, H1V1/2, HCV all are negative.

Renal function test 

  Urea: 72  

 Creatinine: 4.4

Uric acid: 5.5

Calcium: 10.0 

Phosphorous: 4.0

Sodium: 136 

Potassium: 4.3

          Hemogram 

   

       Complete urine examination 

        

  Random blood sugar : 238 mg/ dl 

   ECG 

         

   PROVISIONAL DIAGNOSIS 

  Chronic kidney disease with MHD ( maintainace heamo dalaysis)  

TREATMENT 

1) fluid and salt restriction 

2) Tab.Nicardia 10mgPO/ TID 

3) Tab.LASIX 40mg PO/BD 

4) Tab.Wodosis 500mg BD 

5) Tab Orofer -X OD 

6) Tab. Pantop 40 mg OD 

7) Tab. Shecal 500mg OD