1601006144 SHORT CASE

 HALL TICKET- 1601006144



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SHORT CASE

A 55 years old man, a farmer from Nalgonda came to the OPD with chief complaints of- 

•Swelling in both the legs

•Decreased urine output




HISTORY OF PRESENTING ILLNESS- 
Patient was apparently asymptomatic 10 days back, when he noticed bilateral pedal edema, that developed gradually along with decreased urine output.

•No H/O fever, hematuria, or burning micturition, 

•No H/O of cough, expectoration, chest pain, hemoptysis, reccurent respiratory tract infections.

•No H/O any palpitations, syncope.

•No history suggestive of either hyper or hypothyroidism.



TREATMENT HISTORY-
He's currently on anti- hypertensive medication


GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative, moderately built and moderately nourished. Examined in a well lit room. 

There are no signs of pallor, icterus, clubbing, koilonychia, b/l pedal edema is present. 



Vitals-
Pulse rate- 98bpm 
Respiratory rate- 18 cycles per min
Blood pressure- 130/90mm Hg, left arm
Temperature- Afebrile


CARDIOVASCULAR, RESPIRATORY and ABDOMEN EXAMINATION-
No significant findings
 




INVESTIGATIONS-
Hemogram
complete urine examination

Renal function tests

Ultrasonography


PROVISIONAL DIAGNOSIS: 
Chronic Kidney Disease - Secondary To Systemic Hypertension. 


MANAGEMENT:
Anti-hypertensive medication

For renal failure, regular hemodialysis. 

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