A 61 Yr old male with pedal edema

A 61 Yr old male, farmer by occupation, resident of Suryapet came to OPD on 2 nd Nov 2021

C/O : 1) swelling on both legs since 20 days

          2) shortness of breath since 5 days

HOPI : Patient was apparently asymptomatic 20 days back, then he developed

• Pedal edema : insidious in onset, gradually progressed from just above the ankle to knee level. Right side more compared to left. No aggravating factor, not relieved on medication.
• Not associated with fever.
• Associated with shortness of breath which is grade 4 acc to NYHA , orthopnea present, no PND.
• Patient has reduced urine output since 4 months.

Past history :

• K/C/O hypertension since 15 years 
• Diagnosed with CKD 4 years back
• Went to NIMS with c/o anorexia, dyspepsia, reduced sleep and Sr. Creatinine was found to be 2 mg/dl. Put on dialysis after that. 
• No history of diabetes, asthma, TB, heart disease. 
• No H/O any surgeries 

Treatment history:

• Patient was on medication for CKD for 2 1/2 years after diagnosis
• He is on dialysis since sept 2020 twice weekly. 
• He was being treated in nims hospital

Personal history :

• Diet.              :  mixed 
• Appetite.        :  reduced 
• Bowel.          :  regular 
• Bladder.       :  reduced output since 4 Month
• Addictions   :  absent
• Allergies      :  absent

Family history :

• No h/o CKD in the family

General examination :

Patient is conscious, coherent, cooperative 

Moderate built and moderate nourished 

• Pallor.            : present 
• Icterus           : absent 
• Cyanosis        : absent
• Clubbing        : absent 
• Pedal edema : on right side - till the knee                                on left side - till the ankle 
• Lymphadenopathy : absent 

Vitals : 

• Pulse rate             :  84 bpm 
• Temperature       :  98.2 F
• Respiratory rate  :  20 cpm
• Blood pressure    :  130/80 mm hg 
• Spo2.                     :   99% at RA 

Systemic examination :

Respiratory system: 

Inspection : 

• Trachea                         :  central
• Shape of chest             :  normal
• Movements.                 :  equal on both sides
• Scars, sinuses.             :  absent

Palpation : 

• Trachea.                         : central
•  Movements of chest   : equal on both sides
• Tactile vocal fremitus : equal on both sides 

Percussion :   resonant in all areas

Auscultation : crepitations heard in infra          mammary areas on both sides 

Abdomen examination : 

• Soft, non tender 
• No organomegaly
• Bowel sounds present

CNS examination : 

• Sensory system : normal 
• Motor system : normal
• Cranial nerves : normal 

CVS examination : 

• Heart sounds : s1and s2 heard 

INVESTIGATIONS : 

Provisional Diagnosis : CKD on maintainance hemodialysis 

Treatment : 

• Fluid restriction   : < 1.5 l / day 
• Salt restriction      : <2.4 gm/day
• Inj. Lasix                : 40 mg I. V BD
• Tab nodosis           : 500 mg po BD 
• Tab Bio D 3.           : 0.25 mg po OD
• Tab shelcal ct        : 500 mg po OD 
• Tab orofer             : po BD 
• Inj. Erythropoeitin : S. C weekly twice