65yr old female with SOB and PEDAL EDEMA

A 65 year old female patient resident of nalgonda came to the opd with chief complaints of

• shortness of breath since 1 week

• Pedal edema since 3 months 

• back pain since 1 week 


HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4 years back then she developed flank pain, leg pain and Pedal edema bilaterally for which she consulted local practictioner and then was on medication.

Since it was not subsiding 5 months back she went to nalgonda hospital and was diagnosed with kidney failure .

Now 1 week back she came with complaints of SOB grade 2-3 ,progressive ,aggravated on walking and relieved on rest.



PAST HISTORY

K/C/O hypertension since 10 years

Not a K/C/O DM, TB, Asthma, epilepsy. 


DAILY ROUTINE 


She was a farmer ,daily wage laborer by occupation but she stopped working since 2 years because of back pain and Pedal edema. 

Wakes up at 4Am

Cooking and household activities 

Breakfast at 9am

Talking to neighbours 

Lunch at 12am

Sleep and wakes by 5pm

Dinner at 7pm

Sleeps by 9pm




FAMILY HISTORY

Not relevant 


TREATMENT HISTORY

On anti hypertensive since 10 years regularly 


PERSONAL HISTORY

Diet- mixed

Appetite- loss of appetite since 1 week

Bowel and bladder -regular

Sleep - adequate 

Addictions - none 


GENERAL EXAMINATION

Patient is conscious coherent cooperative

Well oriented to time place person

Moderately built and nourished 


Pallor absent

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema- bilateral Pedal edema since 3 months on and off , non pitting 


VITALS 


On admission

TEMP-afebrile

BP-130/80mm hg

PR- 76bpm

RR- 16cpm 


24/8/22

Temp afebrile

BP 130/70

PR 72 bpm

RR 16cpm 


SYSTEMIC EXAMINATION 


CVS- S1 S2 heard, no murmurs

CNS- NFD

RS- BAE ,NVBS

PA- Soft and non tender 


CLINICAL IMAGES







INVESTIGATIONS 













PROVISIONAL DIAGNOSIS

CHRONIC KIDNEY DISEASE 


TREATMENT

Tab Nicardia 10mg PO BD

tab nodosis 500mg PO BD

tab shelcal 500mg PO OD

Tab orofer XT PO OD

inj erythropoietin 4000IU SC twice weekly 

Inj Pantop p40mg IV BD

inj zofer 04mg IV TID

TAB zincovit PO OD

syp aristozyme 15ml PO TID 20 min before food


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