60 year old male with CKD

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A 60 year old male came with complaints of

B/L pedal edema since 1 month

Tingling sensation in hands and feet since 4 days

HOPI :

Patient was apparently normal 1 month back then he had fever and  developed bilateral pedal edema -upto ankle, pitting type not associated with SOB.

3 years back over a regular health checkup his RFT was found abnormal and was on some medication (unknown) for 3 months.

He continued to work and never had any symptoms after that.

PAST HISTORY :

K/C/O DM since 18 years on insulin s/c for 12 years and 4 months.

After that on vidagliptin.

K/C/O HTN since 4 years on Amlodipine 5 mg.

GENERAL EXAMINATION :

PR- 90bpm

RR- 18cpm

BP- 130/70 mmhg

GRBS- 106 mg%

No pallor, cyanosis, icterus

Edema + (upto ankles)

SYSTEMIC EXAMINATION :

CVS-S1 S2 +

RS- BAE+, NVBS

CNS- NAD

P/A- Soft, non tender

PROVISIONAL DIAGNOSIS :

CKD

INVESTIGATIONS :

On 13/5/22

On 13/5/22

TREATMENT :

1. TAB. VIDAGLIPTIN 100MG PO/OD

2. TAB. AMLODIPINE 10MG PO/OD

3. TAB. OROFER  XT PO/OD

4. TAB. NODOSIS 500MG PO/BD

5. TAB. SHELCAL PO/OD

6. TAB. BioD3 PO/OD WEEKLY ONCE

7. TAB. LASIX 40MG PO/BD

8. FLUID RESTRICTION< 1.5 LIT/DAY

9. SALT RESTRICTION< 2GM/DAY