A 60 YEAR OLD MALE WITH LOSS OF APPETITE AND PEDAL EDEMA

VIJAYA RATNA DANDE 34

 

Hi,I am Vijaya ratna 3rd sem Medical student.This is an online elog book to discuss our patient's health data shared after taking his/her/guardian's consent.This also reflects patient centered care and online learning portfolio.This E-log book reflects my patient- centered online learning portfolio.

Under the guidance of Dr.Durga Krishna Sir[PG]


A 60 year old male farmer by occupation resident of nalgonda came to casualty with chief complaints of

Loss of appetite since 2 months

Pedal edema since 1 month

HISTORY OF PRESENT ILLNESS

   The patient was apparently asymptomatic 2 years back,during this time his nephew got expired and patient started developing anxiety issues and used to take alcohol daily [previously occasional drinker] and after 15 days of expiry of his nephew patient started developing fever, sudden onset,high grade associated with generalized body pains and during this time, patient was diagnosed with hypertension.

Patient used medication for about 3 months and stopped using it.

Patient was normal upto 10 months, during this 10 months period patient started taking alcohol nearly upto 90 ml daily,and patient had sudden onset fever,high grade with low back and generalized body pains.

Then he was taken to local hospital in Miryalaguda, where he was furthre investigated and diagnosed with CKD.

Patient was on Conservative management from that time.

He was normal and used medication upto 1 year and 2 months back patient started developing loss of appetite,gradual onset associated with pedal edema,pitting type,gradual onset,grade III and not associated with any shortness of breath.

No h/o SOB,palpitations,orthopnea,dyspnea on exertion.

No h/o decreased urine output, and abdominal distention.

PAST HISTORY

H/O Hypertension since 2 years [on Tab.Nicardia 20 mg since 1 year]

H/O  CKD since 1 year 

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

PERSONAL HSTORY

Appetite - normal

Mixed diet

Bowels - Regular

Micturition - Normal

Alcohol intake occasionally upto 2 years and from then onwards daily consumes 90ml.

No other addictions 

TREATMENT HISTORY

No specific treatment history

FAMILY HISTORY

His father is a known case of Hypertension

DRUG HISTORY

He has been using Tab.Nicardia 20 mg since 1 year for Hypertension.


GENERAL EXAMINATION

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

VITALS

Temperature - 98.2 F

Pulse rate - 84 bpm

Respiratory rate - 22 cpm

BP - 160/100 mmHg

SpO2 - 98% at room air

GRBS - 109 mg%

Weight - 62 kgs


PHYSICAL EXAMINATION

Pallor - present





Icterus - absent

Cyanosis - absent

Clubbing of fingers/toes - absent

Lymphadenopathy - absent

Edema of feet - present,pitting type ,below the knee from 10 days





Malnutrition -  absent

dehydration - absent


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

INSPECTION

  • No parasternal heave 
  • JVP not elevated 
  • Apical impulse not visible
  • No engorged veins
PALPITATIONS
  • Apex beat felt at 0.5 cm later to the mid clavicular line in 6th intercostal space
All inspectory findings confirmed.

PERCUSSION
  • Heart borders percussed
AUSCULTATION
  • S1 and S2 heard
  • No thrills
  • No murmurs

RESPIRATORY SYSTEM

  • BAE +
  • NVBS +
  • Trachea is in central position
  • No dyspnea
  • No wheezing
PER ABDOMEN

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

CNS

  • NAD


INVESTIGATIONS


                                                                ULTRASOUND


                                                                        ECG



                                                        LIVER FUNCTION TEST



                                                    COMPLETE BLOOD PICTURE



                                            COMPLETE URINE EXAMINATION



                                                RANDOM BLOOD SUGAR



                                                            BLOOD UREA



                                                       SERUM CREATININE



                                                    SERUM ELECTROLYTES



                                                            SERUM CALCIUM



                                                            SERUM IRON



                                                            PHOSPHORUS



PROVISIONAL DIAGNOSIS

CHRONIC RENAL FAILURE


TREATMENT

Tab.Nicardia RSTARD 20 mg PO/BD

Tab Nodosis 500 mg PO/OD

Tab.Orofer XT PO/BD

Tab. Shelcal CT PO/OD

Inj. Erythropoeitin 4000IU [weekly twice]

Inj.Iron Sucrose 10MP in 50 ml NS/IU [weekly once]

Fluid restriction <1.5L/day

Salt restriction < 4 grams /day

Tab.Lasix 40 mg PO/BD


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