GM short case
HALL TICKET- 1601006144
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SHORT CASE
A 55 years old man, a farmer from Nalgonda came to the OPD with chief complaints of-
•Swelling in both the legs
•Decreased urine output
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 10 days back, when he noticed bilateral pedal edema, that developed gradually along with decreased urine output.
•No H/O fever, hematuria, or burning micturition,
•No H/O of cough, expectoration, chest pain, hemoptysis, reccurent respiratory tract infections.
•No H/O any palpitations, syncope.
•No history suggestive of either hyper or hypothyroidism.
TREATMENT HISTORY-
He's currently on anti- hypertensive medication
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative, moderately built and moderately nourished. Examined in a well lit room.
There are no signs of pallor, icterus, clubbing, koilonychia, b/l pedal edema is present.
Vitals-
Pulse rate- 98bpm
Respiratory rate- 18 cycles per min
Blood pressure- 130/90mm Hg, left arm
Temperature- Afebrile
CARDIOVASCULAR, RESPIRATORY and ABDOMEN EXAMINATION-
No significant findings
INVESTIGATIONS-
Hemogram
Renal function tests
Ultrasonography
PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease - Secondary To Systemic Hypertension.
MANAGEMENT:
Anti-hypertensive medication
For renal failure, regular hemodialysis.
