51 yr old male with pedal edema and facial puffiness
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A 51 yr old male patient presented to Opd with cheifcomplaints of pedal edema and facial puffiness since 2 months.History of present illness :
Patient was apparently asymptomatic 1 yr back then he developed pedal edema and facial puffiness for which he visited hospital and diagnosed as renal dysfunction and he was on medication and dialysis also done once and symptoms subsided .
Then he stopped using medications and symptoms recurred and then he visited our hospital and investigations are done and diagnosed as chronic kidney failure.And kept on maintenance dailysis twice a week.
Patient has history of using OTC analgesics frequently for leg pains continuosly for 5 to 6 months
Daily routine before illness:
Patient used to wake up at 5 o clock and he used to climb palm trees for toddy and by 7o'clock patient will return to farm work and he used to eat rice at 10 o'clock in the morning and again returns to farm work and then by 6'o clock in the evening paitent returns to home and complete his natural activities like bathing and take meal at 8 by night and then he goes to sleep.
Daily routine after illnes:
Patient wake up at 8 o'clock and the he eats breakfast only one idly and sometimes skips the break fast and then he is not going for any work and complete bed rest now and now he also takes support of his family members for his natural activities like bathing and going to washroom .His apetite was decreased and he is now not having food properly and goes to bed by 8 o'clock at night.
He is known case of hypertension since 2 months and on medication not a known case of diabetes asthma tuberculosis epilepsy.
Personal history :
Diet :Mixed
Appetite :loss of appetite since 2 months
Bladder movements : decreased urine output since 2 months .
Bowel movements : regular
Sleep : adequate
Addictions :No
Family history:
No history of similar complaints in the family
Treatment history :
No history of allergy to known drugs.
General examination :
Patient was concious coherent and coperative well oriented to time place and person.
- pallor present
-No clubbing
-No cyanosis
-No icterus
-No generalized lymphedenopathy
-pedal edema present pitting type.
Vitals :
Temperature : febrile
Pulse rate: 80 beats per min
Respiratory rate : 17 cycles per min
Bp :130/ 90mm of Hg..
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
Auscultation :
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
Clinical images
Pedal edema :
Pallor :
Investigations
RFT:
Serum electrolytes :
Diagnosis : chronic kidney disease
Treatment :
Salt and fluid restriction
Tab nicardia 10mg BD
Tab lasix 40mg BD
Tab metxl 50 mg BD
Tab PCM 500mg TID
Tab shelcal -CT OD
Tab orofer -XT BD
Inj erythropoietin 4000 IU once a week
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