55 year old male patient with CKD on MHD

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CASE DETAILS :

This is a case of a 55 year old male patient who is a agricultural labourer hails from a rural area of nalgonda district.

He came to the OPD with the chief complaints of 

Shortness of breath since 1 year

Facial puffiness since 1 year

HOPI :

Patient was apparently asymptomatic 3 years back

Then he developed bilateral pedal edema which is of pitting type which was gradually progressive.

He went to the local hospital and diagnosed to have Hypertension on irregular medication - unknown medication

10 months back he developed Facial Puffiness, Shortness of breath and came to KIMS, Narketpally 

Facial puffiness was more pronounced during morning and gradually decreased over the day

Shortness of breath upon rest

Upon investigations he was found to have High Creatinine , shruken kidney size and started on dialysis

PAST HISTORY :

Patient is a known case of hypertension since 3 yrs on irregular medication (Clonidine)

Not a known case of DM , asthma , Tuberculosis, CAD , epilepsy.

NO history of previous surgeries.

PERSONAL HISTORY ::

Moderately built and nourished

Mixed diet

Consumed alcohol occasionally 

Frequency- Weekly once or twice not more than 180ml

for last 20 years stopped since 10 months

Smoking for last 20 years but stopped since 10 months

No smoking history

No drug or food allergies.

GENERAL EXAMINATION ::

Patient is conscious, coherent and cooperative.

He is moderately built and nourished.

Pallor - Present

Icterus - absent 

Clubbing - absent 

Cyanosis- absent 

Lymphadenopathy - absent 

Edema - PRESENT ( BILATERAL PEDAL EDEMA) upto the Knee

VITALS ::

Temp. : Afebrile.

Pulse rate : 84 bpm 

Respiratory rate : 20 per min.

B.P : 140/90 mm of Hg.

spO2 : 98% at room air.

SYSTEMIC EXAMINATION ::

Respiratory system:

Normal vesicular breath sounds heard.

CVS :

S1 , S2 heard , no murmurs.

CNS : 

No sensory and motor abnormalities.

Per abdomen :

Soft and non tender , no organomegaly.

INVESTIGATIONS

on 26/12/2021

On 16/11/2021

PROVISIONAL DIAGNOSIS :

CHRONIC KIDNEY DISEASE on MAINTENANCE HEMODIALYSIS 

TREATMENT ::

One Unit of PRBC transfusion was done on 16/11/2021

Fluid restriction ( less than 1.5litre per day)

Salt restriction ( less than 2gm per day )

Tab. NICARDIA 20mg × po × BD

Tab. Lasix 40mg × po × BD

Tab. Orofer × BD

T Nodosis 500mg × po× BD

 T. SHELCAL PO / OD