Case presentation 7
13.11.21
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65 year old male patient presented to OPD with chief complaints of
. decreased urine output
. pedal edema
. distended abdomen
History of present illness:
Pt was asymptomatic 2 years back and the developed bilateral pedal edema of pitting type of gradually increasing in size and decreased urine output.pt took painkillers since 10 yrs for bodypains and 2 yrs back he developed fever swelling and shortness of breath.he then took medication from a near by medical shop and symptoms resided.4 months back he was brought to OPD with shortness of breath, pedal edema and fever, decreased urine output.
Past history:
A known case of hypertension since 10 years
Not a known case of diabetes mellitus, tuberculosis, hepatitis,epilepsy and asthma.
Drug history:
NICARDIA since 10 yrs
Personal history:
Pt takes mixed diet with decreased appetite.irregular bowel and bladder movements . decreased urine output.
Pt is a chronic alcoholic and took cigars since 40 years.
Routine:pt wakes by 9 am and has rice and goes to work to get toddy from trees and then have lunch and comes back home at 8 and have dinner and then go to bed.
Family history:
No relevant family history.
Treatment history:
No allergy to any known drug.
General examination:
Pt is conscious, coherent and cooperative.he is moderately built and well oriented in place and time.
Signs of pallor and clubbing.no signs of cyanosis, lymphadenopathy .signs of bilateral pedal edema of pitting type.
Vitals
Temp:afebrile
BP:
Pulse rate:
Respiratory rate:20 cycles per min
Systemic examination:
CVS:
no thrills,no cardiac murmurs,
S1 and S2 are heard
Respiratory system:
No dyspnoea and wheezing is present.
Centrally positioned trachea,vesicular breath sounds
Abdomen:
Distended abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.
CNS:
Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves.
Provisional diagnosis:
Chronic kidney disease
Investigations:
Ultrasound
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