1601006007 SHORT CASE

 

1601006007 SHORT

 E-LOGS OF MEDICINE

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             A 52 year old male farmer my occupation came to the opd with chief complaints of 

   -Bilateral swelling in lower limbs since 3 days


     History of present illness:  

        The patient was apparently asymptomatic 1 week back then he developed bilateral swelling over legs since 1 week is which started near the foot and gradually progressed to the knee.

 {pitting type which resolved in between and again started 3 days back}

Past history:

               He had similar complaints in the past for which he went to a local hospital and was advised on taking salt and water restricted diet.

               Patient on telmesartan for hypertension since 2 years.

Personal history:

         He is a chronic alcoholic and smoker.

EXAMINATION:

    Bilateral pedal edema pitting type (GRADE 2) found till knee on general examination. 

Respiratory system :

 Bilateral air entry present 

 Normal vesicular breath sounds heard.

CVS examination : 

No thrills

s1 s2 heard

No murmurs.

Abdomen examination : 

no hepatomegaly or splenomegaly.

   No positive findings found other than edema.


INVESTIGATIONS:

RFT:

HEMOGRAM:


LFT:


PROVISIONAL DIAGNOSIS:

Chronic Renal failure

TREATMENT :

Salt and fluid restriction (<1gm/day <1 lit/day)

Inj. Lasix 40mg

Tab. Nicardia 

Tab. Orofer

Inj. Erythropoietin

Tab. Shelcal

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