1601006113 SHORT CASE

 

1601006113 Short Case



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

A 52 year old male farmer my occupation presented to the opd with chief complaint of bilateral swelling in lower limbs since 3 days


History of presenting 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 of grade 3 found till 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.

Abdomen examination : no hepatomegaly or splenomegaly.

Investigations :

RFT


Hemogram 


LFT 



PROVISIONAL DIAGNOSIS :

Chronic renal failure

TREATMENT :

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

Inj. Lasix 40mg

Tab. Nicardia 10 mg TID

Inj. Erythropoietin

Tab. Shelcal



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