44yr farmer with SOB, Pedal edema, pulsations in neck

SHORT CASE-2

A 44 year old male patient , farmer by occupation  came to OPD with chief complaints of 

Pedal edema since 3 months 

Shortness of breath since 2months

HISTORY OF PRESENT ILLNESS

The patient was apparently  asymptomatic 3months back then he developed bilateral  pedal edema  pitting type, initially it's below ankle & subsided in early morning's , later it's gradually progressed to below the knee and not assocaited with diurnal variation.

He then developed shortness of breath since 2months ,insidious in onset & gradually progressed from grade 1 to grade 2 to 3 currently.

He's also having peri orbital edema & facial puffiness predominantly in morning since 2mnths

He has decreased urine output since 2mnths

No h/o hematuria, fever, chest pain, palpitations, diaphoresis, syncopal attacks

HISTORY OF PAST ILLNESS:-

He has tested positive for covid-19,  3 months

Back & recovered after using medication

known case of Hypertension since 1 year [on tab CILACAR 10mg - morning, 20mg - night].

 Not known case of DM ,Asthma, TB,Epilepsy , CAD

PERSONAL HISTORY

He is married

Occupation - farmer 

Diet - Mixed

Appetite - Normal

Bowels - Regular

Micturition - decreased urine output

He has no known allergies

Occasional Alcoholic since 20 years and stopped 3 months back. 

No smoking 

FAMILY HISTORY

No significant family history

DRUG HISTORY

He has been using Tab. CILINDIPINE 10mg - morning, 20mg -night for Hypertension since 1 year.

SUMMARY AT THE END OF HISTORY:-

A 44yr male patient farmer by occupation who's an occasional alcoholic presented with c/o pedal edema, Sob & decreased urine output with a past history of hypertension and Not a k/c/o DM/Asthma/CAD.

Differential diagnosis:-

Chronic kidney disease

GENERAL EXAMINATION

    Patient is conscious,coherent, cooperative and examined in well Lightned room.

VITALS

Pulse rate -94bpm

Respiratory rate - 28cpm/min

BP - 140/90mmHg

 Temperature - Afebrile

SpO2 - 98% at room air

GRBS - 141mg%


PHYSICAL EXAMINATION

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing of fingers/toes - absent

Lymphadenopathy - absent

Edema of feet- present,pitting type 






SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Jvp elevated

Apex beat in left 5th ICS 1cm lateral to mid clavicular line

S1 and S2 heard

No thrills/parasternal heave / murmers heard


RESPIRATORY SYSTEM 

  • Vesicular breath sounds heard in all area's
  • No wheezing
  • No adventitious sounds heard
ABDOMEN:-
  • No tenderness
  • No palpable mass
  • No free fluid
  • No Audible bruits
  • Liver and spleen are not palpable
  • Bowels sounds are heard


CNS

  • Conscious,normal speech
  • No signs of meningeal irritation
  • Normal gait
  • Cranial nerves are intact 
  • Motor system normal
  • Sensory system normal
  • Reflexes normal
DIAGNOSIS:-
Chronic kidney disease secondary to hypertension. 
INVESTIGATIONS

29/7/2021

ULTRASOUND



ECG



HEMOGRAM


COMPLETE URINE EXAMINATION


BLOOD UREA


SERUM ALBUMIN


TOTAL SERUM PROTEINS(A/G RATIO)



SERUM CREATININE



4/8/2021

SERUM ELECTROLYTES

SERUM IRON


PROVISIONAL DIAGNOSIS

Chronic kidney disease Stage 5 secondary to hypertension. 

TREATMENT

T.Lasix 40 mg PO/BD

T.Cilacar 10 mg PO/OD

T.Nodosis 500mg PO/OD

T.orofer XT PO/BD

T.Cilacar 20 mg PO/OD

Inj.Erythropoietin 4000IU (weekly twice)

Fluid Restriction <1.5L/day

Salt restriction <4gms /day


 

 


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