55 y/o M with b/l pedal edema and facial puffiness
55 y/o male with b/l pedal edema and SOB
Manvi Sharma
Roll no 88
Batch of 2018
Date - 11-3-22
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Chief complaints -
B/l pedal edema since 3 months
SOB grade 3-4 since 1 month
History of presenting illness -
The patient was absolutely alright 11 yrs back when he had an episode of blood in vomitting(?varices) for which he went to the hospital and was given medication which he used for about 1 year. At the same time he was diagnosed to have type 2 DM for which he has been taking oral hypoglycemic agents since then.
From 3 months he complains of b/l pitting edema below knee level. He went to the local hospital where they ran some tests and he was diagnosed to have renal failure for which he received medications. There is complaint of SOB grade 3 since 1 month which is more after consuming food.
Today at about 3 in the morning he had an episode of vomiting - non-projectile, non-bilious and consisting of food contents. The night before he ate and slept with a distended abdomen and heart burn like sensation. Thereby he came to our hospital.
B/l pedal edema +
SOB grade 3 + aggravates on eating food
Facial puffiness +
There is also complaints of blurring of vision from 4 to 5 days and numbness of tongue so that his speech is slightly slurred.
No h/o orthopnea, PND, reduced urine output, chest pain, palpitations, syncopal attacks, cough and fever.
Polyuria and nocturia seen
H/o hypertension since 1 month for which he is taking regular medications
Past history -
K/c/o type 2 DM since 11 yrs and HTN since 1month
Personal history-
Loss of appetite since 10 to 15 days
Diet - mixed
H/o consumption of meat every single day but stopped eating it since 2 months
Bowel & bladder movements - nocturia present(4 to 5 times/night)
Sleep - decreased
Addictions - consumes alcohol everyday but stopped since 2 months, smoke cigarettes about 2/day
About 2 yrs back the patient used to go to work each day i.e he was into catering business but now he just stays at home or sits outside on the road watching people pass by and comes back home.
Family history -
Not significant
VITALS(on admission)
Temp - afebrile
BP - 140/70 mm Hg
PR - 110 bpm
RR - 20 cpm
GRBS - 49 mg/dl
General physical examination -
The patient is conscious, coherent and cooperative and well oriented to time, place and person.
Pallor is seen
B/l pedal edema upto knee is seen
No icterus, cyanosis, clubbing and lymphadenopathy
Systemic examination -
CVS - S1, S2 heard, no murmurs
Respiratory system - NVBS , position of trachea - central
Abdominal system - scaphoid shape, soft and non tender, no organomegaly
CNS - NAD
Investigations-
Serological tests-
HBsAg - negative A
nti HCV Ab - negative
HIV 1/2 - negative
Fasting blood sugar- 106mg/dl
Post lunch blood sugar(PLBS) - 133 mg/dl
Provisional diagnosis -
Chronic renal failure with (?) Diabetic nephropathy
Treatment -underwent dialysis on 13-3-22 in the morning
Tab LASIX
Tab PAN40
Tab NODOSIS
Tab SHELCAL
INJ LASIX
On routine hemodialysis
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