1601006189 SHORT CASE

 1601006189



This is an online E log book to discuss our patient’s de-identified data shared after taking his/her/guardian’s signed informed consent.”

 A 52 year old male  who is a farmer by occupation presented to the opd with chief complaint of 

  • Bilateral swelling in lower limbs since 3 days

H/O Present illness-

The patient was apparently asymptomatic 1 week back then he developed bilateral swelling over legs since 1 week  which started near the foot and gradually progressed to the knee. It was pitting type which resolved in between and again started 3 days back.

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.

He is a chronic alcoholic and smoker.


Examination :

Bilateral pedal edema pitting type up to knee on general examination.

Respiratory system : Bilateral air entry present and normal vesicular breath sounds heard.

CVS examination : No thrills, s1 s2 heard, no murmurs.Apex beat heard in 5th intercoastal space lateral to midclavicular line

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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