A 70 year old female with loin pain and pedal edema

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A 70 year old female resident of Suryapet who is a farmer by occupation came to OPD with 

CHIEF COMPLAINTS:

Loin pain since 1 year

H/o fever since 7days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back then she developed right sided loin pain which is insidious in onset and gradually progressive in nature with no aggravating and relieving factors.She also has a h/o bilateral pedal edema since 7 days which is pitting type.

She has h/o intermittent fever associated with chills 

She also has h/o SOB since 3yrs  which has now progressed to 4th grade

Vomitings since 3 months -2 episodes per day ,non projectile and non bilious with food as content.

No h/o burning micturition,facial puffiness.

PAST HISTORY:

No similar complaints in past

K/c/o HTN

N/k/c/o HTN,DM,epilepsy,TB,CAD

H/o NSAIDs abuse since 2 years for loin pain

H/o head injury 4 years back for which she was  treated or underwent surgery.

PERSONAL HISTORY:

Diet:mixed

Appetite: decreased

Bowel and bladder movements :regular

Sleep: adequate

No addictions

FAMILY HISTORY:

No significant family history

DRUG HISTORY:

Use of NSAIDs for 2 years for loin pain

GENERAL EXAMINATION:

Patient is conscious ,coherent and cooperative 

Moderately built and nourished

Pallor :absent

Icterus:absent

Cyanosis:absent 

Clubbing:absent

Lymphadenopathy:absent

Edema :present

VITALS:

Temperature:98.6*F

BP:110/80mm Hg

Pulse rate:70bpm

Respiratory rate:16cpm

SYSTEMIC EXAMINATION:

CVS examination:

No visible pulsations, scars, engorged veins. No rise in jvp 

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

Respiratory system :

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical

 Bilateral Airway Entry - positive

 Normal vesicular breath sounds

Per Abdominal examination:bowel sounds heard

CNS  : 

No focal neurological disorder found 

Normal speech

LOCAL EXAMINATION:

Inspection:

       On inspection abdomen is flat, symetrical,and slightly distended.

   Umbilcus is centre and inverted

   No scars,engorged veins are seen.

   All 9 regions of abdomen are equally moving with respiration.

Palpation:

      On palpation abdomen is soft and non tender

.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.

Percussion:no shifting dullness, no fluid thrills

PROVISIONAL DIAGNOSIS:

CKD  with NSAID abuse

TREATMENT:

Fluid restriction 

Salt restriction

Inj.LASIX- 40mg IV -TID

Inj.REPOITIN -4000 IV/Weekly once subcutaneously

Tb.SHELCAL- 500mg OD Per orally

Tb.SOBOSIS FORTE -1gm TID Per orally

Tb.Nicardia-10mg per orally

Nebulizer with SALBUTAMOL 6th hourly

Potassium bind sachets in one glass of water per oral TID

Syp.CREMAFFIN -10ml per oral

Cap.BIO D3-Per oral OD weakly once

Tb.ULTRACET -1/2 tab QID

Inj.ZOFER-4mg IV TID.