A 55 year old male with pedal edema since 3 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

R.MANISH KUMAR

ROLL NO-129

CASE REPORT:

A patient aged 55 years auto driver by occupation resident of rajavaram came to opd with chief complaints  of

-Swelling in legs since 3 days   

 History of presenting illness :- Patient was apparently asymptomatic 1yr 4months ago later he had fever for that he went to local doctor but not relieved by medication later after 1 week he developed generalized edema for that he went to nalgonda and they reffered to kamineni hospital .Here he had first episode of dialysis He continued dialysis since then and he missed his dialysis on Saturday and then he developed bilateral pedal edema which is sudden onset non pitting type relieved by dialysis

He developed shortness of breath since Monday grade 1

No history of burning micturition 

No history of vomiting diarrhoea 

Past history :- known case of hypertension and diabetes since 5 years

 No history of asthma epilepsy tuberculosis

Personal history :- Daily routine :- He daily wakes up at 6 am and goes for walking and had breakfast (rice) and goes to his work ..he takes his lunch at 3am and takes his dinner at 10pm .

 Diet :- mixed

Sleep adequate

Bowel and bladder moments :- regular

History of smoking and alcohol since 10 years(smoking 2 packs per day since 10 years and alcohol daily 500ml)

No significant family history

General examination :- patient is conscious coherent and cooperative well oriented with respect to time place and person

Pallor present

No icterus cyanosis clubbing lymphadenopathy

Bilateral pedal Edema present

Afebrile 

BP:- 130/80 

RR :- 16cpm

PR:- 80bpm

Systemic Examination :-

CVS :- S1 S2 heard no murmurs

CNS :- no neurological deficits

RS:- bilateral normal vesicular sounds heard

Trachea central

Per abdomen :- size of abdomen :- obese

No tenderness no palpable spleen and liver

PROVISIONAL DIAGNOSIS:- 

CKD WITH MAINTAINED HEMODIALYSIS 

INVESTIGATIONS:-

Treatment:-

3/01/23

Salt restriction 

Lasix 40mg PO /BD

Nicardia 20 mg PO / BD 

Nodosis 500 mg PO/BD 

Orofer XD PO/BD

Inj erythropoietin 4000iu after every dialysis 

Bio d3 tabs weekly once 

4/01/23

Salt restriction

Lasix 40mg PO/BD

Nicardia 20mg PO/BD

Nodosis 500mg PO/BD

Orofer XD PO/BD

Inj erythropoietin 4000iu after every dialysis 

Bio d3 tabs weekly once 

5/01/23

Salt restriction

Lasix 40mg PO/BD

Nicardia 20mg PO/BD

Nodosis 500mg PO/BD

Orofer XD PO/BD

Inj erythropoietin 4000iu after every dialysis 

Bio d3 tabs weekly once