Case history- 7

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A 65 year old male patient came to the OPD with chief complaints of fever, weakness, swelling of legs, decreased urine output and burning micturition.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back then he noticed generalised weakness, fever, bipedal edema, decreased urine output and burning micturition.

 The patient was diagnosed as renal acute kidney injury  2° to urinary tract infection. 

Dialysis initiated on 12/8/2021 and again readmitted as chronic kidney disease on maintenance hemodialysis on 30/8/2021. Till now 10 sessions of dialysis were done. 

Patient was again readmitted for dialysis. 

PAST HISTORY:

Patient is a known case of hypertension 

No history of diabetes, CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of any surgeries in the past. 

PERSONAL HISTORY:

Appetite: normal 

Diet: mixed

Sleep: adequate 

Bowel and bladder movements: regular

Micturition: normal

Addictions: Alcohol consumption- regular

FAMILY HISTORY:

There is no history of similar complaints in the family. 

TREATMENT HISTORY:

Patient was on regular medication for hypertension. 

GENERAL EXAMINATION:

Patient is conscious, coherent,  cooperative and well oriented to time, place and person. 

There is no signs of icterus, cyanosis, clubbing and generalised lymphadenopathy. 

There is bilateral pedal edema.

VITALS:

Temperature: 98.4°F

Blood pressure: 130/70 mm Hg

Respiratory rate: 24/min

Spo2: 92% at room temperature 

Pulse rate: 84 beats/ min

GRBS: 126 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard

No cardiac murmurs 

RESPIRATORY SYSTEM:

No dyspnoea

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver- not palpable 

Spleen- not palpable 

Bowel sounds- yes

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious

Speech: normal

Signs of meningeal irritation 

       Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

                       HEMOGRAM

                      

                      RFT

          

                          SERUM IRON

         COMPLETE URINE EXAMINATION 

                BLOOD UREA

              SERUM CREATININE 

             SERUM ELECTROLYTES

            URIC ACID SERUM

                    ECG

  DIAGNOSIS:

Chronic kidney disease on maintenance hemodialysis 

TREATMENT:

1. Tab. NICARDIA 10mg TID

2 . Tab. PAN 40mg OD

3. Tab. LASIX 40mg BD

4. Tab. NODOSIS  500mg BD

5. Tab. SHELCAL 500mg OD

6. Tab. Bio D3 0.25mg OD