Short case

A 52 year old male farmer by occupation presented to the opd with chief complaints of 

  • Bilateral swelling in lower limbs since 3 days


The patient was apparently asymptomatic 1 week back then he developed bilateral swelling over legs since 1 week is which started near the foot and gradually progressed to the knee. It was pitting type which resolved in between and again started 3 days back.

He had similar complaints in the past for which he went to a local hospital and was advised on taking salt and water restricted diet.

Patient on telmesartan for hypertension since 2 years.

He is a chronic alcoholic and smoker.


Examination :

Bilateral pedal edema pitting type found till knee on general examination.

Respiratory system: bilateral air entry present and normal vesicular breath sounds heard

CVS examination : No thrills, s1 s2 heard, no murmurs.

Abdomen examination : no hepatomegaly or splenomegaly.

No positive findings found other than edema.


Investigations :

RFT


Hemogram 


LFT 



PROVISIONAL DIAGNOSIS :

Chronic renal failure


TREATMENT :

Salt and fluid restriction (<1gm/day <1 lit/day)

Inj. Lasix 40mg

Tab. Nicardia 

Tab. Orofer

Inj. Erythropoietin

Tab. Shelcal

Comments

Post a Comment

Popular posts from this blog

AKI secondary to UTI

Image
This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission. I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings, investigations, and come up with a diagnosis and treatment plan. ★ CASE SCENARIO : •A 58 year old male patient came to casualty with   chief complaints of: - lower abdominal pain: 1 week  -burning micturation:1week - low back ache after lifting weights -dribbling / decrease of urine out put:1week -fever :1 week - SOB , rest :1week 1. COMPLAINTS AND DURATION: -week back , after weight lifting  Patient had sudden onset of pain in abdomen  By burning micturation with high fever : grade  associated  with chills and rigor  Decrease urine output associated with SOB (grade -4) With no H/O chest pain, palpitations, pedal oedema, facial puffiness. 2.HISTORY OF PRESENT ILLNES
Read more

Medicine case discussion

Image
38 year old female came to casualty with complaints of giddiness since 2 days and headache since 2 days.  HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 1 year back, then she developed giddiness which is on and off and not associated with palpitations, shortness of breath, blackouts, chestpain, sweating, blurring of vision, decreased urine output. 6 months back, she had sudden onset of giddiness followed by fall  with fracture of nasal bone. ENT opinion was taken and on conservative management. She complaints of headache since 6 months which is on and off and holocranial not associated with nausea and vomitings.  She had history of trauma 2 years back for that she went for checkup and diagnosed as DM type 2. Patient had history of pedal edema 1 year back and said to have? Renal problem.  No history of tingling and numbness of foot.  HISTORY OF PAST ILLNESS Known case of diabetes since 2 years No h/o HTN, Bronchial asthma, Tuberculosis. TREATMENT HISTORY On medication fo
Read more