A 45 year old male patient with chronic kidney disease on maintenance of hemodialysis
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A 45 year old male pt c/o decreased urine output, swelling in the legs since 3 years,SOB since 5 days.
HISTORY OF PRESENT ILLNESS:
Pt.was apparently asymptomatic 3 years back. He went to local doctor complaining of weight gain and generalizededema, pitting type.He is on dialysis and medication since 3 years . Suddenly he developed SOB since 5 days which aggrevates on lying down Position.
PAST HISTORY:
He is a known case of hypertension since 2 years.
No H/o asthma, diabetes mellitus,tuberculosis,surgeries.
PERSONAL HISTORY:
Diet - vegetarian
Normal appetite
Bowel and bladder movements-Normal
Addictions- occasional intake of alcohol
FAMILY HISTORY:
No similar complaints in family.
GENERAL EXAMINATION:
Pt is conscious, coherent, cooperative well oriented.
Moderately built and well nourished
No pallor,icterus,cyanosis,clubbing, lymphedenopathy, dehydration.
Presence of Bipedal edema.
Temp-98.4°
PR-86/min
RR-22/min
BP-160/90 mm Hg
SPO2-96%
SYSTEMIC EXAMINATION:
•CVS:
S1, S2 heard
No thrills
No cardiac murmurs
•RESPIRATORY SYSTEM:
Dyspnoea present
No wheezing
Position of trachea -central
Breath sounds vehicular
•PER ABDOMEN:
Shape of abdomen-scaphoid
Non tenderness, no palpable mass, normal hernial orifices.
•CNS:
No focal nuerological deficts
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on maintenance of hemodialysis.
Pitting type of edema:
INVESTIGATIONS:
•COMPLETE BLOOD PICTURE:
Hemoglobin-8.1 gm/dl
TLC-6100
Platelet count-1.47 lakhs/cu.mm
Smear-normocytic normochromic anemia.
HBS Ag -RAPID TEST:
TREATMENT:
1.Fluid restriction <2 l/day
2.salt restriction <2g/day
3.Tab.Nicardia 10mg BD
4.Tab.Lasix 40mg BD
5.Tab.Nodosis 550mg PO OD
6.Tab.Shealcal 500mg PO OD
7.Tab. order PO OD
8.BP charting 8th holy
9.Inj.erythropoietin 400 IU weekly once
ADVICE AT DISCHARGE:
1.Fluid restriction <2 l/day
2.salt restriction <2g/day
3.Tab.Nicardia 10mg BD
4.Tab.Lasix 40mg BD
5.Tab.Nodosis 550mg PO OD
6.Tab.Shealcal 500mg PO OD
7.Tab. order PO OD
Follow up:
SOS
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