A 51 year old male came with chief complaints of pedal edema and sob
A 51 year old male farmer by occupation came to causality with chief complaints of swelling of legs since 1 week and difficulty in breathing 3 days back.
HISTORY OF PRESENT ILLNESS :
The patient was apparantely asymptomatic one week back then he developed pedal Edema which is sudden in onset, gradually progressive with no aggravating and relieving factors. Then he developed shortness of breath which is sudden in onset and gradually progressive with no positional variation. It is associated with decrease in urine output.
There is a history of fever, vomiting and unconscious ness few days before development of symptoms.
PAST HISTORY :
The patient had a history of pedal edema due to chronic kidney failure 1 year back.
The patient is a known case of HTN.
No history of diabetes, epilepsy, asthama, tb.
PERSONAL HISTORY :
appetite :decrased
Patient takes a mixed diet
Bowel and bladder movements :infrequent
Sleep :inadequate
Addictions :patient took alcohol daily for 20 years.
Patient used nasids for 1 year for which he developed chronic kidney failure.
FAMILY HISTORY : insignificant.
GENERAL EXAMINATION :
The patient is examined with an informed consent in a well illuminated room.
The patient is conscious, coherent and cooperative, well oriented to time, place and person moderately build and moderately nourished.
No pallor
No icterus
No clubbing
No cyanosis
No kolionychia
No lymphedenopathy
Pedal edema
VITALS :
PR:
RR:
BP:
TEMPERATURE:
Spo2:
SYSTEMIC EXAMINATION :
CVS:S1, S2+
RE:BAE+
Abdomen examination :no tenderness is being elicited.
Lab tests :
Treatment :
Provisional diagnosis :
Chronic kidney disease caused due to excessive use of nasaids.