Case 8

 A 55 YEAR OLD MALE PRESENTED TO OPD WITH COMPLAINTS - PEDAL EDEMA, FACIAL PUFFINESS AND SHORTNESS OF BREATH

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A 55 year old male who is granite cutter by occupation presented to OPD with chief complaints of swelling of both legs and face and shortness of breath and also cough.

HISTORY OF PRESENT ILLNESS

 Patient was apparent asymptomatic 3months back and he developed cough which is on and off and occasionally wet cough. And 2 months back he developed pedal edema and fever which was decreased on medication and again increased this is continued for about 10days and after 2-3 days he developed shortness of breath and after about 1 week he developed facilal puffiness.

Shortness breath is aggravated by doing work and relieved by taking rest.

HISTORY OF PAST ILLNESS

He had traumatic injury to right side of his eye with stone while working.

There is no h/o of diabetes mellitus , hypertension.

PERSONAL HISTORY

Diet is mixed 

Appetite is reduced

Bowel movements are irregular

He is alcoholic since 30 years and stoped 10 days back and smoking since 30 years daily 1 pack.

GENERAL EXAMINATION

Patient is concious, coherent, cooperative

Pallor is present 

No cyanosis , icterus , lymphadenopathy

Bilateral pedal edema is present which is non pitting type.

Vitals :

Temperature- afebrile

Pulse rate -70bpm

Respiratory rate-20cpm

Blood pressure-140/70mmHg

SPO2- 99%

Systemic examination

CVS- S1 and S2 heard , no murmurs, no added sounds.

 Respiratory system- bilateral air entry +

Trachea is in central position.

Per abdomen- soft, non tender, bowel sounds heard.

CNS- patient is concious

Speech is Present

Reflexes are normal.

PROVISIONAL DAIGNOSIS

CRF 

Investigation

22/11/21

23/11/21

FINAL DAIGNOSIS: polycystic kidney disease.

TREATMENT

Fluid and salt restriction

- Tab. Nicardia 20 mg BD

- Tab. Nodosis 500mg BD

-Tab. Orofer XT po BD

- inj. Erythropoietin 4000units weekely once 

- Tab. Shelcal po OD

Undergone dailysis 4 times after admitted in the hospital.

Followup: 

After 2days that is on dec1st from discharge they said agian there was swelling started  in the feet which was pitting type and fever which was high and decreased on medication. And swelling of lips and he is not able to eat anything because of bad taste. And burning micturition was there which is very high. And pain in the loin region if he sit for a prolonged time.

3/12/21

Underwent dailysis on 7th dec.