Case history-01

Date of admission:5-8-2021

A 50-year-old man presented to the OPD with chief complaints of SOB,decreased urine output and chest pain for the past 7 days.

•HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 10 years back, and then was diagnosed with Diabetes mellitus type2 and was started on Tab.GLIMI M2 OD.
 
4 years back he complained of hypertension and was using anti-hypertensive drugs.

5 days back patient presented to the casualty with pedal Edema,facial puffiness, abdominal distension on and off and diagnosed with CKD,DIABETES NEPHROPATHY.

From past 5 days he complains of constipation and has not passed stools and decreased urinary output since 5 days.

He also complains of altered sleep patterns from past 5 days.
 
•HISTORY OF PAST ILLNESS 
 Not a known case of CAD,Asthma,TB,Epilepsy,thyroid disorders.
There was a BGM operation in past 5 years due to water retention.
•PERSONAL HISTORY 
No history of consuming alcohol and smoking.
Decrease appetite 
Micturation-abnormal
Sleep- inadequate 
•FAMILY HISTORY
No similar complaints in the family 
No history of CVA,CAD,Asthma and thyroid disorder in the family.
•GENERAL EXAMINATION 
Patient is conscious,coherent and cooperative.
There is pedal edema
No cyanosis,clubbing,lymphadenopathy 
•VITALS
Temperature-a febrile 
Pulse rate-98bpm
Respiratory rate -8cpm
BP-16/100mmHg
Spo2 at room air-98%
•SYSTEMIC EXAMINATION 
cardiovascular system:
Thrills-No
Cardiac sounds-s1&s2 heard
Respiratory system:
Dyspnea-present 
No wheezing 
Position of trachea -central
Bilateral air entry- +
Normal vesicular breath sounds-heard
Central nervous system:
Patient is conscious 
Speech -normal
No signs of meningeal irritation
Sensory and motor reflexs-intact 
•PROVISIONAL DIAGNOSIS 
Chronic kidney disease on maintanance hemodialysis
•INVESTIGATION 
RFT
urea-94mg/dl 
Creatinine-3.9mg/dl 
Uric acid-6.9mg/dl
Calcium-9.6mg/dl
Phosphorus-4.3mg/dl
Sodium-135mEq/L
Potassium-3.5mEq/L
Chloride-101mEq/L
•TREATMENT 
Inj. LASIX 40mg IV /BD
Tab. NICARDIA 10mgPO/TID
Tab. ORAFER-XT PO/BD
Inj.ERYTHROPOIETIN 4000IU S/C Once weekly 
Tab. SHELCAL 500mg PO/OD
Tab. NODOSIS 550mg PO/BD
Fluid restriction up to 1L per a day
Salt restriction less than 2 gms per a day 


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