General medicine case-7
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5th November 2021
A 61yr old male patient presented to opd with chief complaint of pedal edema since 1yr and shortness of breath and decreased urine since past 1 year.
Patient is known case of CKD on MHD since 1 year.
HISTORY OF PRESENT ILLNESS:
Patient is asymptomatic 1 year back.Then he developed pedal edema which was gradual in onset and slowly progressive.
Patient has back pain since 1year.
No history of chest pain.
PAST HISTORY:
The patient is known case of hypertension since 6yrs.He is on medication since then.
No history of DM
No history of TB
No history of asthma
PERSONAL HISTORY:
Appetite is normal
Mixed diet
Sleep is adequate
Bowel habits-regular
Bladder habits-irregular-decreased urine output
Patient was alcoholic (kallu)
No smoking habit
FAMILY HISTORY:
No similar complaints in the family
GENERAL PHYSICAL EXAMINATION:
Patient is conscious, coherent and co-operative
No pallor
No icterus, cyanosis and clubbing
Edema of feet is present
VITALS:
Temp:98.4°C
PR:84bpm
RR:24/min
BP:130/70mmHg
spO2:98%
SYSTEMIC EXAMINATION:
CVS:
No thrills
S1,S2 heard
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnoea
No wheezing
Position of trachea:central
Breath sounds: vesicular
ABDOMEN:
Shape of abdomen: scaphoid
No tenderness
No palpable mass
Normal hernial orifices
No free fluids and bruits
Liver-not palpable
Spleen-not palpable
Bowel sounds-heard
CNS:
No abnormality detected
INVESTIGATIONS:
HEMOGRAM:
HIV ANTIBODIES:
HBSAG ANTIBODIES:
BLOOD GROUPING AND RH TYPE:
BLOOD SUGAR-RANDOM:
BLOOD UREA:
RFT:
CBP:
LFT:
SERUM ELECTROLYTES:
SERUM CREATININE:
ULTRASOUND REPORT:
PROVISIONAL DIAGNOSIS:
CKD on MHD
TREATMENT:
Fluid restriction - <1.5gm/day
Salt restriction - <2gm/day
Tab Nicardia -10mg PO/TID
Tab Nodosis - 500mg PO/BD
Tab Orofer - T PO/OD
Tab Shelcal - CT PO/OD
Tab Bio D3 - 0.25mg PO/OD
Tab Lasix - 40mg PO/BD
Inj Erythropoietin - 4000IU - weekly once.
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