45 year old male patient presented to the OPD with cheif complaints of shortness of breath GRADE II-III since 20 days,loss of appetite since 20 days and low back ache since 5 days


HISTORY OF PRESENTING ILLNESS 

45 year old male patient resident of nalgonda, mechanic by occupation. He was apparently asymptomatic 35 days back ,then he developed shortness of breath for which he went to the local hospital ,after further investigation diagnosed with chronic kidney disease and underwent dialysis. (4 times)

 
PAST HISTORY:

No similar complaints in the past 

MEDICAL HISTORY:

He is a known case of hypertension (since 1 month) ,using Tab NICARDIA 10mg
Not a known case of diabetes, tuberculosis, epilepsy, asthma.

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

Mixed diet
REDUCED APPETITE since 3 months 
Adequate sleep
Regular bowel and bladder movement since 15 days

Patient consumes alcohol 1 quarter of whiskey per day since 12 years on regular basis .Last consumption was 20 days back.

He is known smoker of 2 packets of cigarettes per day since 20 years.

GENERAL EXAMINATION:
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present ( pitting type )










VITALS:
Temperature-afebrile
Pulse rate-88 beats per minute 
Respiratory rate-18 breaths per minute 
Blood pressure-140/90mm hg
SpO2-99 at room air

SYSTEMIC EXAMINATION 
Cardiovascular system-S1 and S2 heard ,no murmurs heard

Respiratory system:
Inspection : 
Dyspnoea-present
Breath sounds-vesicular breath sounds are normal

Central nervous system:
Patient was conscious,coherent and cooperative.
Speech was normal
No slurred speech
No Meningeal irritation signs

-No abnormality detected. 

REFLEXES:

Gait : normal 



                          INVESTIGATIONS
Usg report:


LAB INVESTIGATIONS :

Serology:
HBsAg,HIV1/2,HCV all are negative 

Renal function tests:
Urea-209mg/dl
Creatinine-13.6mg/dl
Uric acid-6.9mg/dl
Calcium-9.2mg/dl
Phosphorus-5.9mg/dl
Sodium-143mg/dl
Potassium-4.6mg/dl



Liver function test:
Total bilirubin:1.03mg/dl
Direct bilirubin:0.20mg/dl
SGOT-17 IU/L
SGPT-19 IU/L
Alkaline phosphate:97 IU/L
Total protein 6.6 gm/dl
Albumin:3.0 gm/dl
A/G ratio :0.83



Haemogram:
Haemoglobin-7 gm/dl
Total leucocyte count-4900 cells/cumm
Platelet count:2.49 lakhs/cu.mm




            

          COMPLETE URINE EXAMINATION 

  

Blood sugar random :83 mg/dl

      
                    ECG:


PROVISIONAL DIAGNOSIS:
Chronic kidney disease on MHD 

Treatment :

1.Sali restriction < 2.4 Mg/ day
2.Fluid restriction <4 lit/day
3.Tab Nicardia  20 mg  PO/BD
4.Tab Nodosis 550mg PO/BD
5.Tab Oroder PO/BD
6.Tab Shercal 500mg PO/ OD
7.Inj Erythropoirtin 4000IU s/c weekly once
8.inj Iron sucrose 2Amp in 100 ml during dialysis 
9.Tab Lasix 90 mg /PO/TID

Comments

Post a Comment

Popular posts from this blog

A 32 year ald male

Image
 complaints: Patient complaining of decreased appetite since 10 days , fever since 10 days Vomiting since 7 days associated with pain in abdomen, History excessive alcohol intake since 1 month , aggrevated since last 7 days Loss of weight since 10 days  No H/O fever and lose stools History of presenting illness :  Patient is asymptomatic 10 days back then he had loss of appetite and took no food since then and had excess of alcohol . He developed low grade fever 10 days back , sudden in onset , low grade , intermittent , relieved on medication, associated with rigors , no sweating and no evening rise of temperature. Vomiting since 7 days back , multiple episodes in a day like every 1 hour , bilious, Foul smelling, non projectile , not associated with abdominal pain , no headache, no diminision or blurring of vision . Past history:  No history of Diabetes mellitus, Hypertension, TB , Asthma and No history of any cardiovascular disease History of 2 episodes of admission in hospital in vi
Read more

35 year old with shortness of breath

Image
CHIEF COMPLAINTS A 35 year old who is painter by occupation came with chief complaints of shortness of  breath and fever since 1 week.  HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 1 week back, then he developed  • shortness of breath on exertion, since 1 week. • high-grade fever since 1 week, more during night, relieved on medication and relapses back. • decreased urine output since 1 week • dragging type of pain in both legs and hands, associated with generalised weakness. • orthopnea and PND present since 4 days HISTORY OF PAST ILLNESS No history of DM, HTN, TB, Epilepsy, leprosy, CAD, CVN, Asthma or any other chronic illness. No history of previous transfusion.  PERSONAL HISTORY Built : Weakly nourished Appetite : Decreased since 1 week Diet : mixed Sleep : Decreased since 1 week  Bladder movements:  Anuria since 1 day associated with burning micturition. Bowel movements: regular Addictions : toddy consumer in summer season. Regular alcohol consumer, once a week.
Read more

65 year old male

Image
Chief complaints :  65 year old male with chief complaints with unable to walk since 3 months , muscle stiffness since 20 days , decreased appetite since 15 days . Unresponsiveness since 3 days.  History of presenting illnesses: Patient is apparently asymptomatic 1 year back then developed unbalanced gait,insidious in onset and visited a hospital ,6 months ago and was said to be having a neurological disease (no documents available) and have been using medication since then(not known)and was having generalised weakness on and off since 6 months and due to fear of falling and as he is feeling pricking sensation over the sole,and due to decreased power in his limbs and generalised weakness he completely stopped walking  and was bed ridden since 2 months(he didn’t tried walking even with support)visited a hospital again 1 month back,MRi brain was done,showing hydrocephalus and early parkinsons changes,and advised for surgery (?Ventriculoperitoneal shunting,not done)and during hospital sta
Read more