Case presentation 6

 09.11.21

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A 60 yr old male patient presented to OPD with chief complaints of 

. decreased urine output

.shortness of breath

.pedal edema

H/O present illness

Pt was asymptomatic 5 yrs back and then he developed edema and pain in one of the legs ,visited local hospital and took painkillers .one yr back he developed odema in both legs and visited nalgonda hospital and advised scanning .he was referred to NIMS and was diagnosed with chronic kidney disease.he got dialysis 4 timesamd due to transport difficulties they got admitted to KIMS for their dialysis sessions which was 15 min from their residence.

Past history:

A known case of hypertension since 7 months.

Not a known case of DM,asthma TB.

Treatment history:

Painkillers

Personal history:

Pt takes mixed diet with normal appetite.regular bowel movements and irregular bladder movements.

Pt takes 250 ml of alcohol and chews pan since 8 years.

Routine:

Pt wakes up at 5 am and drinks tea by 5:30 and leaves the house to sell cattle in th market and returns by 12 pm in the afternoon have lunch and stays at home.drinks alcohol and take pan in the evening.takes regular meal during night and go to bed.

Family history:

no relevant family history.

Drug allergy:

Pt is not allergic to any known drug.

General examination:

Pt is conscious, coherent and cooperative.pt is thin moderately built.

Pt show signs of Pallor,no icterus,no cyanosis,no clubbing,no lymphadenopathy,

pt has bilateral pedal edema of pitting type

Temperature: 98.4 F

BP:130/70 mm of hg

pulse rate:84 beats per min

Respiratory rate:24 cycles per min

SPO2 98%

CVS:

no thrills,no cardiac murmurs,

 S1 and S2 are heard

Respiratory system:

No dyspnoea and wheezing

Centrally positioned trachea,vesicular breath sounds

Abdomen:

schaphoid shape of abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.

CNS:

Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves.

Provisional diagnosis:

Chronic renal failure

Investigations:

Treatment:

Salt restoration <2gm/day

 Fluid restoration <1.5 lit /day 

tab NICARDA 20 mg*po*TRD

TAB NODOSIS 500MG*PO*BD

TAB SHECAL 500MG*PO*BD

TAB OROFORXT *PO*OD

inj .ERYTHROPOIETIN 4000IU /weekly once