57 yr old male pt

CASE DETAILS :

This is a case of a 57 year old male patient who hails from a rural area of nalgonda district..

He came to the OPD with the chief complaints of 

* BILATERAL PEDAL EDEMA since 2 months

HOPI ::

Patient was apparently asymptomatic 2 months back

Then he developed bilateral pedal edema which is of pitting type which was gradually progressive. 

He went to a hospital at Hyderabad and 

i/v/o high creatinine levels

4 sessions of Dialysis were done over 1 week

He came to KIMS, Narketpally on 22/12/2021 for further sessions of Dialysis

No history of decreased output, Shortness of breath

PAST HISTORY ::

There were no similar complaints in the past. 

Patient is a known case of hypertension since 2 months on medication ( NICARDIA 10mg)

No DM , asthma , Tuberculosis, CAD , epilepsy.

NO history of previous surgeries.

PERSONAL HISTORY ::

Mixed diet with normal appetite

Bowel and Bladder movements regular ,

Consumed alcohol for last 20 years stopped since 2 months

Smoking for last 20 years but stopped since past 2 months

No drug or food allergies.

GENERAL EXAMINATION ::

Patient is conscious, coherent and cooperative.

He is moderately built and nourished.

Pallor - Absent

Icterus - absent 

Clubbing - absent 

Cyanosis- absent 

Lymphadenopathy - absent 

Edema - PRESENT ( BILATERAL PEDAL EDEMA).

VITALS ::

Temp. : Afebrile.

Pulse rate : 84 bpm 

Respiratory rate : 20 per min.

B.P : 140/90 mm of Hg.

spO2 : 98% at room air.

SYSTEMIC EXAMINATION ::

Lab investigation

PROVISIONAL DIAGNOSIS :

CHRONIC KIDNEY DISEASE on MAINTENANCE HEMODIALYSIS 

TREATMENT ::

Fluid restriction ( less than 1.5litre per day)

Salt restriction ( less than 2gm per day )

Tab. Nicardia 20mg × po × B.D.

Tab. Lasix 40mg × po × B.D.

Tab. Orofer × B.D.

T Nodosis 500mg × po× B.D.

 T. SHELCAL