General medicine case 6

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Date of admission : 27 October 2021

A  48 year old male who is farmer by occupation came to the OPD with the chief complaint of pedal edema

 History of present illness : 

Normal routine of the patient : 

The patient wakes up by 3 AM daily, carries out all the cattle work along with household work, will have his breakfast by 8 AM (rice and curry), goes to the field and does farming, then he used to have his lunch by 1/2 PM (rice & curry or roti) and return home by 6.30/7 in the evening. Then he used to have his dinner (rice again) and sleep by 8 PM.

The patient was apparently asymptomatic 5 years back then he first felt dizziness during a fight in the field (afternoon) for which he consulted a local doctor.

He was diagnosed with hypertension.

He started taking medications prescribed by the local doctor and after few days he experienced back ache and pain in the legs soon after waking up and it subsided by night.

The local doctor suspected a renal problem and the patient was checked for the creatinine levels which were high.

He was continuing medications for renal problem as well.

2 months back the patient was diagnosed with Covid positive when he observed pedal edema and shortness of breath. 

He then came to the OPD with these complaints and was diagnosed with Chronic kidney disease.

The patient now comes to the hospital for dialysis four times a week.

History of past illness :

The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma

He is a known case of hypertension since 5 years

Personal history : 

- The patient has no loss of appetite

- He takes mixed diet

- No sleep disturbances

- He has no addictions

Family history :

- There are no similar complaints in the family members

Treatment history :

- The patient has taken medications for kidney problem 

- He is not a known case of drug allergy.

General examination :

- Patient is conscious, coherent, cooperative at the time of joining

- No Pallor 

- No icterus

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- Bilateral pedal edema is present (pitting type)

Vitals : temperature - 98.4 F

              Pulse rate - 84 bpm

              Respiratory rate - 24 cycles per minute

              BP - 140/90 mm Hg

Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard

https://youtube.com/shorts/tO-ZJaiOgZU?feature=share

RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN 

- abdomen is not tender

- bowel and bladder sounds heard

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Investigations : 

20th september 2021

Hb - 9 g/dl

TLC - 12,800 cells/cumm

Lymphocytes - 18%

Serum iron - 58 ug/dl

Blood urea - 72 mg/dl

Creatinine - 7.9 mg/ dl

Na - 141 mEq/L

K - 4.1 mEq/L

Cl - 97 mEq/L

RBS - 354 mg/dl

26th october 2021

Hb - 5.5 g/dl

Neutrophils - 93%

Lymphocytes - 4%

Platelets - 1.10 lakhs/cumm

Urea - 69 mg/dl

Creatinine - 5.2 mg/dl

Phosphorus - 2 mg/dl

Chlorine - 97 mEq/L

27th October 2021

Hb - 6.2 g/dl

TLC - 12,700

Neutrophils - 84%

Lymphocytes - 8%

RBC count - 2.06 millions per cumm

Urea - 84 mg/dl

Creatinine - 7.0 mg/dl

Uric acid - 10.1 mg/dl

Treatment : 

fluid restriction <1.5/Day

Salt restriction <2 g /day

Tab Lasix 40 mg BD

Tab Nicardia 20 mg BD