70/M paddy farmer with Pedal edema upto thighs & SOB

-
 
70 YEAR OLD MALE PATIENT WITH PEDAL EDEMA AND SOB

CASE DETAILS :
70 year old Paddy farmer, came to OPD with c/o B/L pedal edema and shortness of breath since 6 months

HISTORY OF PRESENT ILLNESS :
Pt was apparently asymptomatic 6 months back, then developed B/L pitting type of pedal edema upto thighs, facial puffiness, anasarca. Then he went to a private hospital in Hyderabad, during routine investigations was told to have elevated creatine levels and was told to undergo dialysis
Pt then came to KIMS, NKP for further management. 
Pt has lost his livelihood since the last 6 months because he's been unable to work. He's survived by his wife and his son who lives elsewhere. He also has two daughters but they don't live with him.
C/o B/L hip pain since 6 months 

No c/o decreased output of urine

No h/o Fever, cough, cold

In KIMS, KNO, pt underwent 10 sessions of dialysis

1st-8/12
2nd-11/12
3rd-15/12
4th-22/12
5th-27/12
6th-31/12
7th-8/1
8th-17/1
9th-22/1
10th-26/1

PAST HISTORY :
Patient is a k/c/o Hypertension and DM since 20 years, on regular medication.
Started on insulin 4months back, twice a day, 10-20 units of insulin

Not a k/c/o TB, Asthma, Epilepsy 

Operated for inguinal hernia 4 years back
H/o Burn 6 years back




GENERAL EXAMINATION :

Patient is conscious/coherent/cooperative 

Moderately built and well nourished

Vitals:

Temp- 98.6F

BP- 140/80 mmhg

PR- 86 bpm

RR- 17 cpm

Spo2- 99% at RA

PHYSICAL EXAMINATION  :

Pallor +

Icterus -

Cyanosis -

Koilonychia -

Lymphadenopathy-

Pedal edema + upto ankle 

SYSTEMIC EXAMINATION  :

CVS- S1 S2 + No murmurs 

RS- BAE+ No added sounds 

P/A- Soft, Non tender 

CNS- NAD







INVESTIGATIONS  :                                              
CHEST X RAY                                                         

ECG
USG : 
TREATMENT :
1. FLUID AND SALT RESTRICTION
2. T. LASIX 40MG PO/BD
3. T. NICARDIA 10MG PO/BD
4. T. OROFER XT PO/OD
5. T. NODOSIS 500MG PO/OD
6. T. SHELCAL CT PO/OD

Comments

Post a Comment

Popular posts from this blog

29 YEAR OLD FEMALE WITH SLE

-
Image
CASE DETAILS : 29 YEAR OLD FEMALE CAME TO OPD WITH COMPLAINTS OF POLYARTHRITIS , SWELLING WITH EARLY MORNING STIFFNESS IN JOINTS,  HAIR FALL, ORAL ULCERS SINCE 3 MONTHS HOPI : PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 15 NOVEMBER 2021. ON 15 NOVEMBER 2021 PATIENT STARTED DEVELOPING FEVER , SWELLING AT SYNOVIUM OF ANKLE JOINT WHICH LATER LEAD TO  PEDAL EDEMA AND  ASSOCIATED WITH REDUCED PLATELET COUNT FOR WHICH SHE WAS TAKEN TO A NEARBY HOSPITAL WHERE  SHE RECEIVED THE TREATMENT AND LATER DURING THE HOSPITAL STAY SHE DEVELOPED PAIN IN ALL JOINTS ASSOCIATED WITH SWELLING AND EARLY MORNING STIFFNESS SINCE THEN. ALSO DEVELOPED PIGMENTATION OVER FACE , SCALP, BOTH EARS , NECK, BOTH HANDS AND LEGS, ARMS AND FOREARMS FOLLOWING WHICH SHE DEVELOPED ORAL ULCERS, THROAT PAIN WHICH IS ON AND OFF , THINNING OF HAIR AND HAIRFALL SINCE 1 MONTH  NO HISTORY OF PHOTOSENSITIVITY,  RAYNAUDS PHENOMENON  PAST HISTORY : H/O 1 EPISODE OF SEIZURES  3 YEARS BACK AFTER SUDDEN DEMISE OF PATIENT'S SISTER. 1 Y
Read more

55 YEAR OLD WITH PEDAL EDEMA AND SOB WITH DIABETES

-
Image
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 -
Read more