Hall ticket no. 1601006126
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Case-
A 55 years old man, resident of Nalgonda farmer by occupation came to the OP with chief complaints of-
-Swelling in both the legs
-Reduced urine output
History of Presenting Illness-
Patient was apparently asymptomatic 10 days ago then he noticed bilateral pedal edema developed gradually and decreased urine output.
No h/o fever, burning micturition, hematuria
No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections.
No h/o palpitations, syncope.
No history suggestive of hypo or hyperthyroidism.
Past medical History- he is a known case of Hypertension
He is not a known case of diabetes mellitus, bronchial asthma, thyroid disorders, epilepsy, coronary artery disease.
Personal history :
-consumes mixed diet
- appetite is reduced
-sleep- adequate
-Bowel movements regular
-bladder habits irregular
Consumes alcohol occasionally
-No habit of smoking and tobacco and Pan chewing
Family history:-
No significant family History
Treatment history:- he is on antihypertensive medication.
General Examination-
Patient is conscious, coherent and cooperative.
He is moderately built and nourished.
He has no signs of pallor, icterus, clubbing, koilonychia, b/l pedal edema is present.
Pulse rate- 98bpm
Respiratory rate- 18/min
Blood pressure- left arm- 130/90mm hg
Cardiovascular examination-
S1 and S2 heard.
No thrills and murmurs
Respiratory system examination-
Bilateral air entry presents, vesicular breath sounds +
No dyspnea, wheezing
Position of trachea- Central
ABDOMEN
Shape of abdomen - Scaphoid
No Tenderness
No Palpable mass
Hernial Orifices - Normal
No Free Fluid
No Bruits
Liver Not palpable
Spleen - Not palpable
Investigations:-
Ultrasonography finding- Renal parenchymal disease of grade- 2.
Provisional Diagnosis: Chronic Kidney Disease etiology- secondary to systemic Hypertension.
Management:-
Tablet- Laxix 40mg
Tablet- Nicardia 20mg
Tablet- Met xl
Tablet- Nodosis
Tablet- Arkamine
Tablet- human atropine.
With respect to renal failure, compensated by regular hemodialysis.
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