55 YEAR OLD WITH PEDAL EDEMA AND SOB WITH DIABETES

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55 YEAR OLD MALE PATIENT WITH PEDAL EDEMA AND SOB WITH DIABETES 

CASE DETAILS 
A 55 YEAR OLD MALE PATIENT CAME TO THE CASUALITY WITH 
C/O PEDAL EDEMA SINCE 3 MONTHS
NAUSEA AND VOMITING SINCE 10DAYS
SOB SINCE 10 DAYS

HISTORY OF PRESENT ILLNESS 
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR BACK THEN HE SUFFERED WITH FEVER ASSOCIATED WITH HEMATEMESIS FOR 10 DAYS AND RECOVERED AFTER USING MEDICATION AND WAS LATER DIAGNOSED AS DIABETIC AND STARTED MEDICATION.
3 MONTHS BACK HE DEVELOPED PEDAL EDEMA( GRADE III - IV ) WHICH WAS GRADUALLY PROGRESSIVE AND PITTING TYPE ALONG WITH FACIAL PUFFINESS PRESENT
NAUSEA AND VOMITING SINCE 10 DAYS 
SOB SINCE 10 DAYS 
NO H/O REDUCED URINE OUTPUT, BURNING MICTURITION 

PAST HISTORY 
 
K/c/o DM SINCE 10 YEARS 
NO H/O HTN, ASTHMA, EPILEPSY

PERSONAL HISTORY 
DIET - MIXED 
APPETITE  - NORMAL 
SLEEP  -  ADEQUATE 
BOWEL AND BLADDER - REGULAR 
NO ADDICTIONS

GENERAL EXAMINATION

Patient is conscious/ coherent /cooperative

Moderately built and nourished

Vitals :

Temp - Afebrile

BP - 130/90 mmHg

PR - 78 bpm

RR - 18 cpm

GRBS - 325 mg / dl

PHYSICAL EXAMINATION

Pallor +

Icterus - 

Cyanosis -

Koilonychia -

Lymphadenopathy -

Pedal edema present upto thigh

SYSTEMIC EXAMINATION

CVS - S1 S2 + No murmurs

RS  -  BAE + No added sounds 

P/A - Soft , Non Tender

CNS - NAD





INVESTIGATIONS

ECG


CHEST XRAY


ABG


11/03/2022





PROVISIONAL DIAGNOSIS 

CRF WITH DIABETIC NEPHROPATHY

TREATMENT 

1. TAB. LASIX 40 MG / PO/BD

2. TAB. PAN 40 MG / PO/ OD

3. TAB. NODOSIS 500 MG/ PO/ OD

4. TAB. SHELCAL 500 MG / PO /OD

5. INJ. HAI S/C TID ACCORDING TO SLIDING SCALE





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