General medicine case -2

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Date of examination :- 17/8/2021

    A 58yr old male presented to OPD with chief complaints of decreased urine output, swelling in the legs,shortness of breath since 5 months.

History of present illness:-

Patient was apparently asymptomatic 5 months ago then he had developed pedal edema and decreased urineoutput.

*He also complaints of shortness of breath.

History of past illness :-

*pedal edema since 10 years.

*Hypertension since 5 months. 

* Has history of blood transfusion.

*Not a known case of Diabetes, CAD,asthama,epilepsy and thyroid disorder.

Personal history:-

Diet:-past:-mixed

Present:-vegetarian

Appetite:-Normal

Sleep:normal 

Bowel:-Regular

Micturation:-No urine output 

Addictions:alcohol addiction 10 years ago,present no addictions.

Family history :-

Has a history of Hypertension In family (mother)

No history of similar complications in family members.

Treatment history :- 

He was treated priorly with medications for pedal edema for 10 years recommended by local medical practitioner.

.He is taking medication for hypertension.

No history of past drug allergy.

General examination:-

-Patient is conscious,coherent and cooperative well oriented to time place and person.

-Their is bilateral pedal edema(Pitting type) and palor.

-No H/O Cyanosis ,Clubbing ,Lymphadenopathy 

Vitals :-

TEMPERATURE:-99°F

PULSERATE:-80bpm

BLOOD PRESSURE:-170/90mm of hg

SpO2:-98%

Respiratory rate:-15cycles per min

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 

-Ausculation:

S1 ,S2 Heard

-PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 

Central nervous system :- 

-Patient is conscious 

-Reflexes are normal 

-Speech is normal

Investigations:-

Pedal edema:pitting type

Haemogram:

Haemoglobin:-7.3gm/dl (reduced)

Total count:-14500cells/cumm

Neutrophil:-91% (raised)

Lymphocytes:-04%.(reduced)

MCHC:-35.8%(raised)

Serum creatinine:5.7mg/dl

RFT:

Urea:-64mg/dl

Creatinine:-5.7mg/dl

Chloride:-92mEq/l

Random blood sugar :-165mg/dl

LFT:

SGOT:-40IU/L

ALKALINE PHOSPHATASE:-333IU/L

Ultrasound report:-

Final diagnosis :- 

Chronic kidney disease 

Treatment:- 

1)Tab Lasix-40mg /BD

2)Tab Nodosis 500mg TID

3)Tab shelcal 500mg OD

4)TAB OROFEX XT BD

5)TAB pantop 40mg OD