General medicine case presentation 5

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

Chief Compliant:
70 year old male patient farmer by occupation presented to opd with complaint of swelling of legs since 1 1/2 month &vomiting since 10 days. Shortness of breath. 

History of present illness:
Patient was apparently asymptomatic since 1 1/2 month. 
Patient c/o of pedal edema since 1 1/2 month, progressive, putting type, bilateral & presence of facial puffiness. Shortness of breath, oliguria, abdominal distension. 
Hiccups since 15 days. 
C/o vomiting , containing food particles, urinary hesitancy, dribbling of urine. 

History of past illness:
H/o bilateral pedal edema 2ys back, used medication &pedal edema resolved. 
K/c/o HTN since 1 1/2 yr

Treatment history:
No  history of drug allergy

Personal history:
Diet: Mixed
Appetite:Normal
Bowel & Bladder Movements: Regular
Addictions:
Alcohol 90ml occasionally
Tobacco 1 chotta pack per day stopped since 3 yrs
Family History:
No similar complaints in the family

General & Physical Examination:
No pallor
No cyanosis
No icterus 
No clubbing
B/l pedal edema grade 2 pitting type

Vitals
Temperature : normal
Pulse rate : 78/min
Bp:200/100mmHg
Spo2: 98%

Systemic Examination:
CVS:
No thrills
No cardiac murmers
S1, S2 sounds heard
Respiratory system:
No dyspnoea
No wheeze
Decreased AE on left RSA, IAE
Abdomen:
Shape of abdomen- Scaphoid
No tenderness
No palpable mass
Normal hernial orifice
No free fluid
CNS:
Conscious 
Speech normal
Motor system, sensory system normal. 
Cranial nerves normal. 

Provisional Diagnosis:
Renal failure

Investigations:
CUE
Hemogram
ECG
Uric Acid Serum
Serum creatinine
Serum electrolytes (Na, k, cl) 
ECG:

Serum creatinine:
Serum uric acid :
Treatment:
Salt restriction <2gm/day
Fluid restriction <1L/day
INJ LASIX 40mg IV BD
Monitor vitals
I/O charting
Inj neomol 1gm IV /sos 
Tab PCM 650mg Po /sos.


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