Case 02

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Date of examination:- 17/8/2021

    A 58yr old male presented to OPD with chief complaints of decreased urine output, swelling in the legs,shortness of breath since 5 months.

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 5 months ago then he had developed pedal edema and decreased urineoutput

*He also complaints  of shortness of breath.

HISTORY OF PAST ILLNESS:-

*pedal edema since 10 years.

*Hypertension since 5 months. 

* Has history of blood transfusion.

*Not a known case of  Diabetes, CAD,asthama,epilepsy and thyroid disorder.

PERSONAL HISTORY:-

Diet:-past:-mixed

Present:-vegetarian

Appetite:-Normal

Sleep:normal 

Bowel:-Regular

Micturation:-No urine output 

Addictions:alcohol addiction 10 years ago,present  no addictions.

FAMILY HISTORY:-

Has a history of Hypertension In family (mother)

No history of similar complications in family members.

TREATMENT HISTORY:-

He was treated priorly with medications for pedal edema for 10 years recommended by local medical practitioner.

.He is taking medication for hypertension.

No history of past drug allergy.

GENERAL EXAMINATION:-

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

Their is bilateral pedal edema(Pitting type) and palor.

No H/O Cyanosis

 No H/O  Clubbing

No H/O Lymphadenopathy.

VITALS:-

TEMPERATURE:-99°F

PULSERATE:-80bpm

BLOOD PRESSURE:-170/90mm of hg

SpO2:-98%

Respiratory rate:-15cycles per min

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard

PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal

INVESTGATION:

Pedal edema:pitting type

Haemogram:

Haemoglobin:-7.3gm/dl (reduced)

Total count:-14500cells/cumm

Neutrophil:-91% (raised)

Lymphocytes:-04%.(reduced)

MCHC:-35.8%(raised)

Serum creatinine:5.7mg/dl

RFT:

Urea:-64mg/dl

Creatinine:-5.7mg/dl

Chloride:-92mEq/l

Random blood sugar  :-165mg/dl

LFT:

SGOT:-40IU/L

ALKALINE PHOSPHATASE:-333IU/L

Ultrasound report:-

Final diagnosis:

Chronic kidney disease

Treatment:

Tab 

Lasix-40mg/BD

Nodosis 500mg TID

Tab shelcal 500mg OD

TAB OROFEX XT BD

TAB pantop 40mg OD