Case about A 50 year old male with SOB,Pedal edema, decreased urine output, dryness of mouth.

 General medicine case 06

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A 50 year old male who is used to work as daily worker came to OPD with Chief complaints of shortness of breath since 10 days , pedal edema, decreased urine output , tiredness, appetite lost, dryness of mouth, nausea since one month.

History of Present illness:-

Patient was asymptomatic 15 years ago. Then he diagnosed with kidney failure 15 years back with complaints of nausea, pedal edema,decreased urine output, shortness of breath and he went to hospital and had done 1 session of Hemodialysis and treated conservatively (on and off).

And now he came to OPD with complaints of shortness of breath since 10 days ago, pedal edema, tiredness, appetite lost, dryness of mouth, nausea , decreased urine output .

Routine:- He wakes up at 4 A.M daily. He doesn't have breakfast instead has tea by 8 A.M . And he watch t.v and do some work. By 1 P.M he will have his lunch. He will have a nap from 2P.M to 3P.M and he goes out. By 7 P.M he comes to home. By 8 P.M he will have dinner . By 9 P.M he goes to sleep.

Past History:-

Patient has Hypertensive since 2 months.

No history of Diabetes, Asthma , Tuberculosis, Epilepsy , Anemia.

Patient 3 years ago has diagnosed with liver disease with complaints of ascites, nausea, dizziness, appetite lost and treatment was taken and it was subsided.

Personal History:-

Patient takes mixed diet.

Sleep is adequate.

Appetite lost.

Bowel  movements regular.

Bladder movements irregular.

Consumption of alcohol daily from 10 years back and stopped since 3 years back.

Smoking since 15 years .

Family history:-

No family members has similar complaints.

Treatment History:-

Patient is on Nefidinol.

He is on DOLOMAC 650.

General examination:-

Patient was conscious, coherent and alert.

Patient shows generalised weakness.

No anemia , no pallor , no cyanosis, no icterus , no clubbing of fingers 

No generalised lymphadenopathy.

Patient have pitting pedal edema.

Vitals:- 

Temperature :- afebrile

Respiratory rate :- 18 cycles per min.

Pulse rate:- 98 beats per min.

Blood pressure:- 110/90 Hg mm.

Systemic Examination:-

CVS -- Cardic sounds s1, s2 

            No Cardiac murmurs

Respiratory system --- Dyspnea

                                        No wheezing sound 

                                Position of trachea is central

CNS ---- Patient is conscious

              Speech is normal

              Reflexes are normal

 

Abdomen--- abdomen is tender

                   bowel sounds heard   

                   Moderate free fluid.

Investigations:- 

 

Provisional diagnosis:-

Chronic kidney disease with Polycystic kidney disease with hyponatremia with HTN .

Treatment:- 

Fluid restriction < 1 L a day

Salt restriction < 2 g a day

TAB . LASIX 40 mg PO/TID

TAB. NICARDIA 10 mg PO/TID

TAB. OROFER- XT PO/BD

INJ. Erythropoietin 4000 IU S/C once weekly

TAB. NODOSIS 550 mg PO/BD

TAB. SHELCAL 500 PO/ OD