60M with CKD and HTN
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A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with
Chief complaints
-Pedal edema since 3 months
-shortness of breath since 20 days
- decreased urine output since 15 days
History of presenting illness
The patient was apparently asymptomatic 3 months back then developed bilateral pedal edema initially extending to ankle Gradually progressed up to thighs which worsened during last 15 days.
Decreased urine output since 15 days, not associated with frequency, urgency burning micturation.
Grade 3 shortness of breath, noaggravating and relieving factors.
PAST HISTORY
Known case of hypertension since 6 months
No history of diabetes mellitus, asthma, cardiovascular disease , epilepsy, tuberculosis
no history of blood transfusions.
Personal history
Married
Farmer
Mixed diet
Sleep adequate
Bowel-Regular
Bladder-Irregular
No allergies known
Occasionally consumes alcohol
Smokes tobacco
FAMILY HISTORY
Hypertension persent(father)
GENERAL EXAMINATION
Patient is conscious,coherent, cooperative.
Pallor, clubbing ,pedal edema are present.
Icterus,Cyanosis, lymphadenopathy are absent.
Vitals
Temp:99.1°F
PR: 98
Rr: 29/ min
Bp:100/80 mm Hg.
Spo2: 84%
GRBS:124 mg/dl
Systemic examination
Cardiovascular system:
-S1,S2 heard .no mumurs.
Respiratory system:
-Position of trachea central.
- Bilateral airway entry present.
-Dyspnea present
- no wheeze.
Abdomen:
-Scapoid
-No tenderness
-No palpable mass
-Spleen : not palpable
-liver : not palpable.
CNS examination:
-Conscious .
-no signs of meningeal irritation.
FEVER CHART
Clubbing:
Pitting type
INVESTIGATIONS
SEROLOGY
HIV 1/2 Rapid : Non reactive
Anti HCV antibodies Rapid : Non reactive
HBsAg Rapid : negative
HEMOGRAM
On 28/11/23
- Hemoglobin:5.4gm/dl.
-total count: 26,800
-Neutrophils- 89
-lymphocyte:5
-eosinophil:06
- monocyte :0
-Basophils:0
-PCV : 16.1
-MCV : 84.1
-MCH : 28.1
-MCHC : 33.4
-RDW -CV :22.9
-RDW-SD : 66.3
- platelet count : 1.32
Impression: Normocytic Normochromic with neutrophilic leukocytosis and thrombocytopenia.
On 29/11/23
- Hemoglobin:5.4gm/dl.
-total count: 22,300
-Neutrophils- 91
-lymphocyte:4
-eosinophil:0
- monocyte :5
-Basophils:0
-PCV : 16.2
-MCV : 84.4
-MCHC : 28.3
-MCHC : 33.5
-RDW -CV :22.1
-RDW-SD : 66.9
- platelet count : 1.52
Impression: Normocytic Normochromic with neutrophilic leukocytosis.
Renal funtion test
On 28/11/23
Urea 131 mg/dl
Creatinine 4.6 mg /dl
Uric acid 9.9 mg/dl
Calcium 10.1 mg/dl
Phosphorus 5.1 mg /dl
Sodium 137 meq /l
Potassium 4.1 meq / l
Chloride 102 meq/l
On 29/11/23
Urea 146 mg/dl
Creatinine 7.7 mg /dl
Uric acid 10.8 mg/dl
Calcium 9.9 mg/dl
Phosphorus 5.6 mg /dl
Sodium 129 meq /l
Potassium 4.7 meq / l
Chloride 89 meq/l
ABG REPORT
On 28/11/23
PH 7.46
Pco2 29.4 mmhg
Po2 165 mmHG
Hco3 20.7 mol /l
Tco2 44.9vol
O2 sat 98.8 %
O2 count 8.9vol %
On 29/11/23
PH 7.74
Pco2 25.9 mmhg
Po2 46.1 mmHG
Hco3 19 mol /l
Tco2 43.3 vol
O2 sat 92.4 %
O2 count 2.4 vol %
ECG
PROVISIONAL DIAGNOSIS
Chronic kidney disease on maintenence hemodialysis with anemia of chronic disease with hypertension
TREATMENT
On 28 /11/23
Patient was on salt restriction < 1.5 g / day
Patient was on fluid restriction <1.5l per day
Inj : PIPTAZ 2.25 gm iv /tid
Inj LASIX 40 mg iv /bid
Inj MEOMOL 14 mg iv sos if temp >101
Tab : ECOSPRIN 50mg H/S
Tab : OROFER once a day
Tab DOLO 650 mg every 6 hourly
Tab NODOSIS 500 mg PO /BD
Tab SHELCALT 500 mg /BD
On 29/11/23
TAB. LINOD 10mg twice a day.
Inj LASIX : 40 mg Iv twice a day
Tab : Oral NODOSIS 500 mg twice a day
Tab: Oral SHELCAL 500 mg twice a day
Inj.EPO 4000 IU ,SC once weekly
Tab : oral ECOSPRIN 75mg H/S
Inj NEOMAL : 14mg IV sos
Tab : DOLO 650 mg QID
Inj PIPTAZ : 2.25 gm I.v thirice a day.
On 30/11/23
Inj PIPTAZ : 2.25 gm I.v twice a day.
Inj LASIX : 40 mg Iv twice a day
Inj NEOMAL : 14mg IV sos
Tab : Oral NODOSIS 500 mg twice a day
Tab: Oral SHELCAL 50 mg twice a day
Tab : oral ECOSPRIN 50mg H/S
Tab OROFER once a day
Tab : DOLO 650 mg QID
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