LONG CASE
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January 18 , 2023
A 65 year old male came with the chief complaint of bilateral pedal edema and shortness of breath since 1 week
Date of admission 17 /01 /2023
HISTORY OF PRESENT ILLNESS:
- patient was apparently asymptomatic 10 years back then he met with an accident
-later he diagnosed with heart problem following which he started using NSAIDS
- H/o episode of tonic seizure at night 5yr back - phenytoin 100mg bd
- Bilateral pedal edema, SOB and he was taken to hospital where he diagnosed with NSAIDS induced nephropathy with hypertension
- 12 sessions of heamodialysis was done and later was on conservative management ( August 2021)
-Pedal edema pitting type aggregated on standing relieved on lying down
-Facial puffiness, decreased urine output
-No H/o chest pain
-No H/o palpitations
-No H/o burning micturition
-SOB since one week insidious in onset
gradually progressing from grade 2 to 3 sometimes grade 4 , orthopnea present
-No H/o fever , cough , cold , wheeze
HISTORY OF PAST ILLNESS:
- known case of CKD since 5 years
- Known history of hypertension
- No H/o DM, asthma,TB
TREATMENT HISTORY:
Patient is on a regular medication of
Phenytoin and clinidipine
PERSONAL HISTORY
-Diet : mixed
-Appetite : lost since 5 years
-Bowel and bladder movements : regular
-Sleep : disturbed since 1 week
-Habits : alcohol( occasionally) Tobacco smoking ( regular 10 - 12 beedies per day)
-Drug allergy : no known drug allergies
- Marital status : married
FAMILY HISTORY
-NO relevant family history
GENERAL EXAMINATION
Patient was concious coherent cooperative and well oriented to time place and person
-Moderately build
-Moderately nourished
-Pallor -absent
-Icterus- absent
-Cyanosis- absent
-Clubbing - absent
-Generalized lyphadenopathy - absent
-Bilateral pedal edema - present
VITALS
-temperature - afebrile
-Pulse rate - 89bpm
-Respiratory rate - 22cpm
-Blood pressure -140/80mmhg
-Spo2 - 94%
SYSTEMIC EXAMINATION
cvs
Inspection
-Chest wall : symmetrical
- No Dialated veins
Palpation
-Apical impulse : present at 5th intercostal space
- No Dialated veins
Auscultation
-S1 , S2 heard ,no murmurs
respiratory system
-Dyspnoea - present
-Wheeze - present
Inspection
-Chest : symmetrical
-Trachea position - central
-Drooling of shoulders : no
-No scars
- No Dialated veins
Palpation
-Chest movements : symmetrical
-Treachea position - central
Auscultation
-Vesicular breath sounds
Abdomen
Inspection
-Shape - distended
-Flanks - full
-Umbilical position - central
-Skin - no scars
-Dialated veins - no
Palpation
Superficial palpation :
-No tenderness
- No localised raise in temperature
Deep palpation :
-Liver , spleen , kidney are not palpable
Auscultation
-Bowel sounds - Heard
-Bruit - not heard
CNS
-Consciousness
-Speech : normal
-No neck stiffness
- kerning sign - negative
-Memory intact
PROVISIONAL DIAGNOSIS
CKD with hypertension
INVESTIGATIONS
TREATMENT
01 .Tab. Lasix 40mg po/bd
02 .Tab. Nodosis 500mg po/bd
03 .Tab. Orofer po/od
04 . Tab .shelcal po/od
05. Tab . Phenytoin 100mg po/od
06 .Tab .metxl 25mg po/od
07. Tab . Isolazine po/od
08. Cap . Bio D3 po/once weekly
09 . Inj. EPO 4000IU onc / week
