57 yr old male with bilateral pedal edema and decreased urine output
A 57 year old male came to OPD with complaints of bilateral leg swellings and decreased urine output
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P.Navyasri
2K18
ROLLNO-111
A 57 year old male resident of gopalpally farmer by occupation came to OPD with
INSPECTION :
cheif complaints of
- bilateral leg swellings since 7 days
-decreased urine output since 2 days
-excess sweating since 4 hours .
HISTORY OF PRESENTING ILLNESS-
-Patient was apparently asymptomatic 15 years back then developed polyuria and polyphagia and diagnosed with Diabetes mellitus and he is on oral hypoglycemic drugs .
- 5 years back he developed right arm and leg paralysis then he was diagnosed with Hypertension and now he is on metXL- 25.
- He had bilateral pedel edema upto knees , facial edema since 7 days
- H/O hand swelling since 6 days
- H/O decreased urine output and burning micturition since 2 days
- H/O shortness of breath since 1 day ; which is not associated with cough , aggrevated on walking , relieved on rest.[Grade 1/2]
PAST HISTORY -
- He is known case of Diabetes since 15 years ,
(GluconormPG1 metformin + glimiperide + pioglitazone ),
- Hypertension since 5 years(metXL 25mg)
- Not a known case of TB, epilepsy, asthma
- No history of previous surgeries
PERSONAL HISTORY -
-He wakes up at 4:30 am then he goes to his farm do agriculture work
-Then after 1 hour he comes to home and have tea and then goes again for the work
- then comes in the afternoon and have lunch ( rice and dal )
- for dinner also he will have rice
-Appetite is decreased
- Sleep is adequate
- Bladder - decreased urine output since 2 days
- Bowel movements - regular
- Addictions - consumes alcohol
since 40years -Full bottle daily
Since 2 months - quarter
H/O smoking 25 years ago
Presently he quitted smoking
GENERAL EXAMINATION -
-Patient is conscious, coherent and cooperative and Well oriented with time , place and person .
-He is well built and nourished
-No signs of pallor , icterus , cyanosis , clubbing , generalised lymphadenopathy .
-He is having bilateral pedal edema , pitting type since 7 days .
VITALS :
-Temperature : 94.6°F
-PR:102bpm
-RR:16cpm
-BP:190/120mmhg
-SpO2 :96%
-GRBS : 55mg%
SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION :
Shape of abdomen- Obese.
Scar present.
No engorged veins.
Hyperpigmented spots on Right Side of abdomen
PALPATION :
No local rise of temperature .
No tenderness .
No palpable mass.
Liver and Spleen - Not palpable .
PERCUSSION:
Normal liver span.
Tympanic note heard over stomach region .
ASCULTATION:
Bowel sounds heard.
CVS:
-S1,S2 heard ,
-No murmers
RS:
-Dyspnea - grade 1 or 2 present
-Trachea is central
-Bilateral air entry present
-Normal vesicular breath sounds heard
INVESTIGATIONS :
8/10/22
9/10/22
PROVISIONAL DIAGNOSIS :
Acute kidney injury secondary to
? Diabetic nephropathy
? Nephrolithiasis
Recurrent hypoglycemia secondary to ? OHA
Treatment:
1.Inj.25%D infusion@50ml /hr
2.IVF NS @urineoutput +30ml/hr
3.inj.LASIX 40mgIV BD
4.tab.NICARDIA 20mg BD
5.tab.ARKAMIN 0.1mg TD
6.tab.NODOSIS 500mg BD
7.tab.SHELCAL 500mg OD
8.tab.bioD3 weekly
9.tab.MET XL 25mg OD
10.inj.MEROPENUM 500mg IV/BD
11.inj.BICARB 50meq IV/BD
