Case of a 60yr old male with pedal Edema and reduced urine output.

 


April 23, 2021

CASE OF A 60 YEAR OLD MALE WITH Pedal OEDEMA and decreased urine output. 

This is the case i have been given :


A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine output since 4 months

2. Bilateral pedal edema since 4 months 


HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type.

There is history of pruritus and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CAD, CVA, TB, asthma, epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions :  h/o beedi smoking 4-5 years ,stopped 1 year back


GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present


• No Icterus, cyanosis,clubbing, koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type



VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal

• SpO2: 97% on RA


SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS:

All higher motor functions are normal

Cranial nerves intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs


• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard


INVESTIGATIONS :

Complete blood picture


Complete urine examination


Serum iron



Renal function tests



Liver function tests


Blood grouping & Rh typing


HIV

HbsAg




Anti HCV Antibodies




SARS COVID




USG




ECG 



TREATMENT GIVEN :

The patient was on hemodialysis along with drugs
Hemodialysis chart








Fluid & salt retention (< 1 litre/day and <2gm/day )
Tab. Nicardia 10 mg TID
Tab. Lasix 40 md BD
Tab. Nododis 500 mg BD
Tab. Shelcol OD
CAP - alpha -D3 OD
Sodium bicarbonate
Injection iron sucrose 100 mg BD
Injection Monocef 1g BD
Injection erythropoietin 4000 iu/ one weekly

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