65 year old female patient complains of pedal edema

 

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Chief complaint: 

A 65 year old female patient presented to OPD with a complaint of  pedal edema and decreased urine output since 1 week .

History of present illness :

Patient was apparently asymptomatic 1 year back and suffered lower back pain and noticed mild pedal edema and undergone symptomatic treatment and got resolved of the condition .Then 2 months back   she developed pedal edema and shortness of breath  , weakness in lower limbs then she visited nearest hospital .

Past history :

Patient was known case of hypertension since 1 year .she had history of lower back pain 3years back for which she took relevant treatment and it was resolved.She had an  eye surgery 15 years back .

Personal history:

Diet -mixed diet

Appetite-normal 

Bowel and bladder movements -regular

Sleep -adequate

No addictions 

Family history:

No relevant family history 

Menstrual history:

Menopause at 45 years 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. 

Moderately built and moderately nourished.

Nopallor,icterus,clubbing,cyanosis, and lymphadenopathy.  

VITALS : 

Temperature-afebrile 

Pulse rate -88bpm

BP-140/80mmHg 

RR-19cycles /min

Spo2-98%At RA

 Systemic examination

CVS:-

No thrills

S1 S2 heard 

No cardiac murmurs 

RESPIRATORY SYSTEM:-

No dyspnea,No wheeze

Position of trachea -central

Breath sounds -vesicular

ABDOMEN:-

Shape of abdomen -scaphoid 

No tenderness,Normal hernial orifices

Spleen -not palpable

Liver -not palpable

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on MHD 

INVESTIGATIONS:

Complete blood picture :

Anti HCV antibodies-RAPID:-

HIV 1/2 Rapid test:-

BLOOD GROUPING AND RH TYPE:-

HBsAg-RAPID:-

SERUM ELECTROLYTES( Na,K,Cl)

LIVER FUNCTION TEST :-

SERUM IRON:-

BLOOD UREA:-

SERUM CREATININE:-

Blood sugar -random

ECG:-

Treatment :-

Fluid restriction less than 1.5L/day

Salt restriction less than 2 g/day 

T.NICARDIA-10mg PO /BD

T.NODOSIS 500mg/PO/BD

T.SHELCAL PO/OD

INJ . ERYTHROPOIETIN 400 IU S/C weekly twice

T.OROFER XT  PO /BD