A 32 YEAR OLD MALE WITH PEDAL EDEMA AND OLIGURIA

 34 D VIJAYA RATNA 

Hello Everybody! This is vijaya ratna, a third semester medical student.

This elog depicts the patient-centered approach to learning. This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, after taking his/her/guardian's signed informed consent. This elog also reflects patient’s centered learning portfolio.

      NOTE :- This is an ongoing case and will be updated as and whenever required.

      Under the guidance of Dr.Deekshitha

 A 32 year old male patient, labourer by occupation came to OPD with chief complaints of

Pedal edema since 10 days

Less urine output since 10 days

HISTORY OF PRESENT ILLNESS

 The patient was asymptomatic one year ago and developed diminision of vision consulted doctor and was diagnosed with hypertension for which he has been using Tab.Arkamin and Tab.Telma H since 1 year.

He developed pitting type of edema below the knee since one month, weakness and backache since one month which relieved on rest.

He has decreased urine output and consumes alcohol [180ml] rarely.

HISTORY OF PAST ILLNESS

known case of CKD on MHD since 1 month

Known case of HTN since 1 year (on Tab.Arkamin , Tab Terma H)

Not a known case of DM,CAD,Asthma,TB,Epilepsy

 

PERSONAL HISTORY

 He is single

Occupation – Daily Labourer

Diet – Mixed

Appetite – Normal

Bowels – Regular

Micturition – decreased urine output

Has no known allergies

Drinks alcohol rarely[180ml]

TREATMENT HISTORY

     No specific treatment history

FAMILY HISTORY

     His brother is a k/c/o HTN

DRUG HISTORY

     He has been using Tab.Arkamin and Tab.Telma H since 1 year for HTN.

GENERAL EXAMINATION

      Patient was conscious,coherent,cooperative and examined in a well lit room.

VITALS

 Pulse rate : 98bpm

Respiratory rate : 18/min

BP : 150/80mmHg

Temperature : Afebrile

GRBS : 127mg%

SpO2: 98% at room air

PHYSICAL EXAMINATION

 Pallor – absent

Icterus – absent

Cyanosis – absent

Clubbing of fingers/toes – absent

Lymphadenopathy – absent

Edema of feet – present,below the knee, pitting type.

Malnutrition – absent

Dehydration – absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

• S1 and S2 heard
• No thrills
• No cardiac murmurs

RESPIRATORY SYSTEM

• Vesicular breath sounds heard
• Trachea is in central position
• No wheezing
• No Dyspnoea 

 ABDOMEN

• Obese shaped abdomen
• No tenderness
• No palpable mass
• No hernial orifices
• No free fluid
• Liver and spleen not palpable
• Bowels sounds are heard

CNS

• Conscious and normal speech
• Normal gait
• Cranial nerves normal
• Sensory system normal
• Motor system normal

REFLEXES

                      RIGHT         LEFT

 Biceps            +2                   +2

Triceps            +2                   +2

Supinator     +2                    +2

Knee                +2                    +2

Ankle              +2                   +2

INVESTIGATIONS

    28/07/2021

                                                                 ULTRASOUND

ECG

   29/07/2021

                                                                              ECG

2D ECHO

        

    30/07/2021

                                                       HEMOGRAM

 

PROVISIONAL DIAGNOSIS

         CKD on MHD secondary to Hypertensive nephropathy

  DIAGNOSIS       

            Heart failure with preserved ejection fraction

PLAN OF MANAGEMENT

      Renal Transplantation

        Discussion is going on regarding ABO Compatibility

TREATMENT

Fluid restriction <1L/day

Salt restriction <2.4L/day

T.Lasix 40mg PO/BD

SAM – 4pm

T.Nicardia 20mg PO/TID

T.Arkamine 0.1 mg PO/BD