1702102065 SHORT CASE

CASE: 

A 65 year old male came to the OPD 4 days ago with pedal edema, decreased urine output and shortness of breath.

HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 1.5 years ago when he developed pedal edema which was gradual in onset and progressive in nature. He developed an ulcer 6 months ago on the left foot for which he went to a doctor and was prescribed medication. He then developed fever and cough 18 days ago. He then developed shortness of breath

PAST HISTORY:
No similar complaints in the past
The patient was diagnosed with hypertension 10 years.
He does not have diabetes mellitus, tuberculosis, epilepsy, or asthma
No surgical history 
No radiation exposure 

PERSONAL HISTORY:
Diet- mixed
Appetite-normal
Sleep-inadequate
Bowel movements- regular
Bladder: normal 
Addictions- consumes alcohol daily -180ml
                   Bidi- 2 packs a day

Allergies-none

FAMILY HISTORY:
There is no significant family history.

GENERAL EXAMINATION:
The patient was conscious, coherent and co - operative. 
He is well oriented to time, place and person.
No pallor
No icterus
No clubbing
No cyanosis
No generalized lymphadenopathy
 skin is dry
Bilateral pedal edema is present 
 



VITALS:
pulse rate: 90bpm
blood pressure:140/90 mmhg
respiratory rate:22 cycles/min
Spo2: 98% at room air

SYSTEMIC EXAMINATION:
CVS: S1 and S2 are heard
         No thrills and murmurs
RESPIRATORY SYSTEM: 
Normal vesicular breath sounds are heard
BAE present
No dyspnea
ABDOMEN:
Shape of abdomen: scaphoid
No tenderness, no palpable mass, no free fluid, liver and spleen are not palpable 

 



CENTRAL NERVOUS SYSTEM: 
Speech: normal
No neck stiffness
Cranial nerves -N

INVESTIGATIONS: 
30/8/2021



Haemoglobin : 8.8gm/dl






Blood urea: 127mg/dl
 


Serum creatinine: 8.3mg/dl
 


Serum sodium: 132mEq/l

ECG: 
  

PROVISIONAL DIAGNOSIS: CKD

TREATMENT:
  1. Tab nicardia 20mg BD
  2. Tab lasix 40mg BD
  3. T orofer XT - BD 
  4. Tab shelcal 500mg OD
  5. Injection erythropoietin 400IU once weekly
  6. Inj iron sucrose 1 amp in 100ml normal saline - once a week
  7. Fluid (<1.5 litre) and salt (<4gm) restriction 

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