A 75 yrs old male patient with Cheif complaints of fever and pedal edema

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CHEIF COMPLAINT :-

A 75 years old male patient who is farmer by occupation  presented to the Opd with a chief complaint of fever since one month, pedal edema since 15 days. SOB. 

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic one month back then he developed fever which was low grade, intermittent for which he visited the local hospital, prescribed with paracetamol.

15 days back   he developed bilateral pedal edema of pitting  type, inscidous,gradually progressive below the knee, along with fever for which they again visited a local hospital and was told that the both kidneys got failed.

5 days back when he presented to the OPD he had SOB of grade 3.

PAST HISTORY:

K/c/o hypertension since 6 months.

No history of diabetes, asthma, tuberculosis.

He underwent hernia surgery 20 years back. 

He underwent cataract operation 15 years back.

PERSONAL HISTORY :

Appetite - lost since 15 days. 

Bowel-regular. 

Micturition - abnormal. 

Habits - occasional alcoholic. 

               He was a smoker 7 years back he 

                 Stopped smoking.

Diet - mixed. 

Sleep - adequate.

FAMILY HISTORY :

No similar complaints in the family.

GENERAL EXAMINATION :

Patient is conscious, coherent, cooperative and he is moderately built, nourished.

No pallor,cyanonis, clubbing, icterus. 

No lymphadenopathy. 

Edema - present which is of pitting type, incidous in onset,gradually progressive below the knee. 

Vitals :-

Temperature - afebrile

Pulse-98bpm.

Respiratory rate - 15cpm.

Bp-150/90mmperhg

Spo2-100%

SYSTEMIC EXAMINATION :

Bilateral airway +

Position of trachea - central. 

Normal vesicular breath sounds - heard 

No added sounds 

PER ABDOMEN:

abdomen is soft and non tender 

Bowel sounds heard 

CENTRAL NERVOUS SYSTEM 

Patient is conscious 

Reflexes are normal 

Speech is normal 

Clinical images 

Pedal edema 

INVESTIGATIONS :

Serum iron 

Liver function test (lft) 

Blood urea - 

Serum electrolytes - 

Serum creatinine 

Complete urine examination - 

Hemogram - 

Blood sugar - 

ECG

Fever chart - 

PROVISIONAL DIAGNOSIS - 

chronic renal failure associated with hypertension. 

TREATMENT :-

Fluid restriction <1.4l/day.

Salt restriction <2.4gm /day. 

Tab LASIX 40mg po/bd

TAB NICARDIA 10mg  po/tid 

TAB SHELCAL-CT po/od

CAP  BIO-D3 po/od

TAB NODOSIS 500mg po/od