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:
Hemoglobin-8.1gm/DL
Platelet count-3.37L/cumm
RBC count-2.69millions/cum
Lymphocytes-14%
Total count-7,700cell/cumm
HCV antibodies - non reactive
HIV test - non reactive
HBsAg antibodies - negative
RFT
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
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