55 yr male with pedal edema and facial puffiness

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 A 55 yr old male patient presented to Opd with cheifcomplaints of pedal edema and facial puffiness.

 

History of present illness : 

     Patient was apparently asymptomatic 3 yrs back then he has paralysis and then later he recovered .

    Then 4  months back he noticed pedal edema And visited nearby hospital and given symptomatic treatment and diagnosed with diabetes and hypertension and kidney problem.

   But pedal edema not subsided on symptomatic treatment and then they came to our hospital.

And he was put on dialysis  twice a week.

     Personal history :

Diet :Mixed 

Appetite :loss of appetite since 2 days 

Bladder movements : decreased urine output since 4 days .

Bowel movements : irregular

Sleep :inadequate since 2 days 

  Alcoholic since 15 yrs drinks daily 250ml.

 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 : Afebrile

Pulse rate: 82 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.

Clincal images :

Treatment:

Tab 

Lasix-40mg/BD

Nodosis 500mg TID

Tab shelcal 500mg OD

TAB OROFEX XT BD

TAB pantop 40mg OD