General medicine case 5

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4 October 2021

25 year old male came to the casualty with cheif complaint of pedal edema since 1year and shortness of breath and decreased urine since past 1 and half year.

Patient is known case of CKD on MHD since 1 and half year.

HISTORY OF PRESENT ILLNESS:

The patient is asymptomatic 1 and half year back,then he developed pedal edema which was gradual in onset and slowly progressive.

Patient has shortness of breath on exertion and decresed urine output.

No history of chest pain.

No c/o palpitations.Since then, patient is on MHD.

PAST HISTORY:

The patient is known case of TB and hypertension.

PERSONAL HISTORY:

Appetite is normal

Mixed diet

Sleep is adequate

Bowel habits - regular

Bladder habits - irregular-decreased urine output

No addictions

FAMILY HISTORY:

No similar complaints in the family

GENERAL PHYSICAL EXAMINATION:

Patient is conscious, coherent and co-operative.

Pallor -present

No icterus , cyanosis and clubbing.

Edema of feet is present

VITALS 

Temp:98.4°C

PR:96bpm

RR:24/min

BP:140/100 mmHg

spO2:98%

SYSTEMIC EXAMINATION:

CVS:

No thrills 

S1 , S2 heard

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea - present on exertion

No wheezing

Position of trachea:central

Breath sounds-vesicular

ABDOMEN:

Shape of abdomen-scaphoid

No tenderness

No palpation

No bruits

Liver - not palpable

Spleen - not palpable

Bowel sounds are present

CNS:

No abnormality detected.

INVESTIGATIONS:

HEMOGRAM:

HCV antibodies - non reactive

HIV test - non reactive

HBsAg antibodies - negative

RFT

CBP

ECG

ABG

BLOOD UREA

SERUM CREATININE

SERUM IRON

SERUM ELECTROLYTES

BLOOD GROUPING AND RH TYPE

B+ve

PROVISIONAL DIAGNOSIS:CKD ON MHD

TREATMENT:

1.Fluid restriction <1.5L/day

2.Salt restriction <2gm/day

3.Tab Lasix 40mg PO/BD

4.Tab Nicardia 20mg PO/TID

5.Tab Arcamine 0.1mg PO/TID

6.Tab Met-XL 50mg PO/OD

7.Tab Orofer-XD PO/BD

8.Tab Shelcal 500mg PO/OD

9.Inj erythropoietin 4000 IU/SC- once weekly

10.BP ,PR, spO2 and temp monitoring

11.Tab Dolo 650mg TID

12.H - 3 tablets - 300mg

      R - 3 tablets - 450mg

      Z - 1 tablet - 750mg