General Medicine Case8

 

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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:

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.