A 46 year old male with pedal edema and shortness of breath
31 August 2022
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K. Phani Keerthana
Roll no 72.
A 46 yr old male resident of suryapet presented with cheif complaints Of Bilateral pedal edema since 2 months and shortness of breath since 10 days.
HOPI-
Past history-
Known case of DM since 8 years and on medication
HTN - Since 3 years and on medication
No H/o asthma epilepsy leprosy CAD
Personal history-
Diet - mixed
Appetite - normal
B&b - normal
Addictions - Alcohol since 22 yrs every alternate day.
He has toddy, whisky and all other variants of full glass
He stopped alcohol since his 1at visit to hospital for bilateral pedal edema 3 yrs back.
Allergies - none
Family history-
Not sisignificant
General examination-
Patient was conscious coherent cooperative well oriented to time place and person
Patient was examined in a well lit room and consent was taken.
Vitals -
PR-106 bpm
BP-120/60
RR-16cpm
SPo2-98%
Temp-Afebrile
Pallor - Absent
Icterus - absent
Clubbing - Absent
Cyanosis- Absent
Lymphadenooathy- absent
Edema - b/l pedal edema present (pitting type)
GRBS - 167mg/dl.
CVS - S1, S2 heard
Resp -
CNS - NFD
Per Abdomen - soft non temder and distended abdomen
INVESTIGATIONS
Haemogram-

2D Echo
PROVISIONAL DIAGNOSIS
CKD on MHD with fluid overload secondary to renal failure
Treatment -
On 29/8/2022
Fluid and salt restriction
Inj. Lasix - 40mg i/v
Inj pantop
Tab nicardia 20 mg
Tab isosorbide dinitrate
Tab carvidilol
Tab shelcal - 500 mg B/d
Tab orofer-xt
On 30/8/2022
Fluid and salt restriction
Inj. Lasix
Inj pantop
Tab nicardia
Tab isosorbide dinitrate
Tab Nodosis
Tab orofer xt
Nebulizer with budicort- 12 th hrly
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