NEPHROLOGY CASE

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82 YEARS OLD MALE PATIENT WITH SOB AND PEDAL EDEMA

CASE DETAILS

82 year old male patient came to the OPD with chief complaints shortness of breath and bilateral pedal edema since 3 months associated with intermittent chest pain and cough since 15 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 years back then developed fever with burning micturition and diagnosed HTN by local RMP doctor and was on medication,  3 months back he developed shortness of breath more while lying down (orthopnea) associated with cough (wet type sputum present) 

H/O bilateral pedal edema since 3 months and pitting type

H/O chest pain which is intermittent since 15 days

No H/O burning micturition, decreased urine output, fever, palpitations.

PAST HISTORY

K/C/O Hypertension Since 4 years on medication Tab Telmisartan 40 mg

Not a K/C/O DM, TB, Asthma, Epilepsy

PERSONAL HISTORY

Diet - Mixed

Appetite - Decreased

Sleep - Adequate

Bowel & Bladder - Regular 

GENERAL EXAMINATION

Patient is conscious/ coherent /cooperative

Moderately built and nourished

Vitals :

Temp - Afebrile

BP - 160/70 mmHg

PR - 78 bpm

RR - 18 cpm

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


USG


2D ECHO

04 /03 /2022

09/03/2022


PROVISIONAL DIAGNOSIS

HEART FAILURE WITH PRESERVED EJECTION FRACTION DIAGNOSED AS  CHRONIC RENAL FAILURE ASSOCIATED WITH HYPERTENSION

TREATMENT

1. FLUID RESTRICTION < 1.5 LT/DAY

2. SALT RESTRICTION < 2 GM /DAY

3. TAB. LASIX 40 MG / BD

4. TAB. NICARDIA 10 MG / BD

5. TAB. NODOSIS 500 MG / BD

6. TAB. SHELCAL 500 MG / OD

7. CAP. BIO D3 0.25 MG / OD

8. TAB. OROFER XT / BD

9. INJ. IRON SUCROSE 100 MG IN 100 ML NS / IV OVER 1 HR

10. INJ. ERYTHROPOIETIN 4000 U/ SC X ONCE WEEKLY

11. TAB. MET XL 12.5 MG / OD


12/03/2022

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