44 yr old male patient complaints of pedal edema since 10 days and decreased urine output since 5 days
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Chief complaints:
A 44year man who is a farmer by occupation came to OPD with chief complaints of:
1)B/L pitting type of pedal edema since 10 days and decreased urine output since 5 days
2)pain in the abdomen since 4 days
3)vomiting since a day.
History of presenting illness:
He was apparently asymptomatic 1 and 1/2 yrs back , then he developed swelling in face and lower limbs and visited doctor , and was on medication . He stopped medication after 10 days.
After few days he had difficulty in breathing (SOB grade 2) and decreased urine output
He was admitted to hospital and was on dialysis for 2 days .
Since then he was on dialysis twice every week.
Patient was apparently asymptomatic 10 days back and gradually developed B/L pitting type of pedal edema which was & decreased urine output.
Patient developed pain in the epigastric region since 4 days ,which is of pricking type, non radiating, aggravated after food and relieved on its own after some time .
Patient also showed history of vomiting of 6-7 episodes which was non bilious , consisted of food particles and was relieved on medication .
Past history:
K/C/O HTN since 4 years, but he didn't take any medication for it.
N/K/C /O DM ,TB , EPILEPSY, ASTHMA.
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel n bladder: irregular , decreased urine output progressed to anuria.
Addiction: alcohol consumption qty: 180ml 3-4 times a week at night , since 15years, stopped since 1and 1/2 year.
No History of smoking
Family history:
LFT:
ABG:
HEMOGRAM:
ABG
Plan of treatment:
1.Fluid and salt restriction
2. INJ. ZOFER 4 mg IV/ TID
3. INJ. TRAMADOL 1 AMP in 100 ml NS IV / SOS
4. TAB. NICARDIA 10 mg PO/TID
5. TAB. ARKAMIN 0.1mg PO/BD
6. TAB. MET- XL 25 mg PO/OD
7. TAB. SHELCAL 500mg PO/ OD
8. Cap. BIO-D3 PO/OD/WEEKLY ONCE
9. INJ. ERYTHROPOIETIN 4000 IU S/L WEEKLY TWICE
10. BP MONITORING 2nd hrly
11. GRBS 2nd hrly.
Chief complaints:
A 44year man who is a farmer by occupation came to OPD with chief complaints of:
1)B/L pitting type of pedal edema since 10 days and decreased urine output since 5 days
2)pain in the abdomen since 4 days
3)vomiting since a day.
History of presenting illness:
He was apparently asymptomatic 1 and 1/2 yrs back , then he developed swelling in face and lower limbs and visited doctor , and was on medication . He stopped medication after 10 days.
After few days he had difficulty in breathing (SOB grade 2) and decreased urine output
He was admitted to hospital and was on dialysis for 2 days .
Since then he was on dialysis twice every week.
Patient was apparently asymptomatic 10 days back and gradually developed B/L pitting type of pedal edema which was & decreased urine output.
Patient developed pain in the epigastric region since 4 days ,which is of pricking type, non radiating, aggravated after food and relieved on its own after some time .
Patient also showed history of vomiting of 6-7 episodes which was non bilious , consisted of food particles and was relieved on medication .
Past history:
K/C/O HTN since 4 years, but he didn't take any medication for it.
N/K/C /O DM ,TB , EPILEPSY, ASTHMA.
Personal history:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel n bladder: irregular , decreased urine output progressed to anuria.
Addiction: alcohol consumption qty: 180ml 3-4 times a week at night , since 15years, stopped since 1and 1/2 year.
No History of smoking
Family history:
There is no significant history seen in the family.
General examination:
Patient is conscious, coherent and cooperative and well oriented to time, place and person,
On examination:
General examination:
Patient is conscious, coherent and cooperative and well oriented to time, place and person,
On examination:
VITALS:
Pallor present( mild) , no icterus/ clubbing/ cyanosis / lymphadenopathy /edema (apparently)
Temp: 98°F
BP : 140/100mmHg
RR: 28/min
PR : 80/min
SPO2: 99% @ RA
Temp: 98°F
BP : 140/100mmHg
RR: 28/min
PR : 80/min
SPO2: 99% @ RA
SYSTEMIC EXAMINATION :
CVS: S1 S2 +
RS : BAE +
CNS : NAD
P/A : tenderness and pain in the epigastric region
CVS: S1 S2 +
RS : BAE +
CNS : NAD
P/A : tenderness and pain in the epigastric region
Investigations:
RFT:
RFT:
LFT:
ABG:
ECG:
HEMOGRAM:
ABG
SERUM ELECTROLYTES:
TROPONIN:
Provisional diagnosis:
?acute gastritis
CKD on MHD, HTN +
CKD on MHD, HTN +
Plan of treatment:
1.Fluid and salt restriction
2. INJ. ZOFER 4 mg IV/ TID
3. INJ. TRAMADOL 1 AMP in 100 ml NS IV / SOS
4. TAB. NICARDIA 10 mg PO/TID
5. TAB. ARKAMIN 0.1mg PO/BD
6. TAB. MET- XL 25 mg PO/OD
7. TAB. SHELCAL 500mg PO/ OD
8. Cap. BIO-D3 PO/OD/WEEKLY ONCE
9. INJ. ERYTHROPOIETIN 4000 IU S/L WEEKLY TWICE
10. BP MONITORING 2nd hrly
11. GRBS 2nd hrly.
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