55 year old male with SOB&pedal edema
55 yr old male with SOB & Pedal edema
July 18, 2023
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CHEIF COMPLAINTS:
A 55year old male male, resident of Suryapet who has been staying at home since the past 10 years, was brought to the casualty with chief complaints of:
Shortness of breath since 15 days
B/L pedal oedema since 7 days
Reduced urine output since 7 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 15 days back, then he developed SOB(grade I-II), that was insidious in onset, gradually progressing, no aggravating or relieving factors present.
He complained of B/L pedal oedema since 5 years, aggravated since last 7 days, pitting type, extending upto the knee. Not relieving on medication.
C/O reduced urine output since 7 days.
No C/O chest pain, palpitations, orthopnea, PND.
No H/O fever, burning micturition, loose stools, vomiting.
No C/O pain abdomen.
Daily routine
10 years ago, he used work as as a farmer
Woke up at 5am, had breakfast around 7am and left for work by 8am. He packed his lunch which he ate at his workplace around 1pm, and came home by 7pm
He ate at 8pm and slept at 10pm
10 years back, he met with an accident while attending a funeral and had a fractured left femur that was conservatively treated. So he took a break from work.
A few months later, he slipped and fell at his house and had a similar fracture in the right hip joint that was also treated conservatively.
After this, he stopped working as he needs support of sticks to walk around.
Now his routine has changed as follows
Wakes up at 6am, has breakfast at 7am and sits in the veranda for a while.
Then goes inside his house, eats at 1pm, sits with wife/son/neighbour for the afternoon, has dinner at 8pm and sleeps at 10pm
PAST HISTORY:
No history of similar complaints in the past
He was diagnosed with CKD 1 month ago, is on irregular medication
Not a k/c/o Diabetes, Hypertension, Asthama, Epilepsy, Tuberculosis
No history of any previous surgeries
PERSONAL HISTORY
Diet - Mixed
Appatite - Normal
Sleep - Reduced
Bowel and Bladder - Reduced urination, normal bowel.
No known Allergies
Addictions
Alcohol - about 90ml per day since his teenage.
Beedi - 1 packet per day since his teenage.
FAMILY HISTORY
No history of similar complaints in the family.
GENERAL EXAMINATION
The patient is conscious,coherent and cooperative, well oriented
He is moderately build and well nourished.
Pallor - present
Icterus- present
Clubbing-absent
Cyanosis-absent
Lymphadenopathy-absent
Edema - B/L pitting type present, extending upto the knee
Vitals:
Temperature -afebrile.
Pulse rate - 94/ minute
Respiratory rate - 20/minute
Blood pressure (left arm) - 100/60 mm of Hg
GRBS - 105 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 and S2 heard. No addded thrills or murmurs heard
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
ABDOMEN:
*non tender
*soft
CNS:
Conscious and coherent.
Normal sensory and motor responses.
INVESTIGATIONS :
Hemogram
Complete Urine Examination
Provisional Diagnosis
The patient is suffering from Chronic kidney disease, with bipedal edema
