Case history -1


 August 09 ,2021

 Date of admission-09-08-2021

A 53year old men presented to the OPD with a chief complaint of dialysis from Past 4 yrs .

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptotic 4 yrs back and then noticed swelling in the body and decrease in urination .since then he has been on medication .

Patient is undergoing dialysis twice a week .

3 days back the patient is suffering from stomach pain and was presented to causality .

PAST HISTORY:

Not a known case of HTN ,CAD,asthma ,epilepsy,thyroid diseases .No history of surgeries in the past .

PERSONAL HISTORY:

Normal appetite ,the patient is non vegetarian,regular bowel movement,normal sleep ,no addictions .

FAMILY HISTORY:

No history of diabetics melitus ,asthma ,thyroid disorders in the family .No cancer deaths in family .

GENERAL EXAMINATION:

Patient is conscious,coherent ,cooperative ,patient is having fistula in the left hand .

No Palar 

No clubbing 

No cyanosis 

No pedal Edema 

VITALS :

Temp :afebrile 

Bp :160/100mm Hg

PR:84bpm(regular)

CVS:s1,s2, no murmur 

RS:NVBS,

P/A-soft 

SYSTEMIC EXAMINATION:

Cardiovascular system :

No thrills 

No cardiac murmurs -s1,s2+

Respiratory system :

No dysponea 

No wheeze 

Position of trachea-central 

Abdomen :

Shape of abdomen -scaphoid 

No tenderness 

No palpable mass 

Hermial orifices -normal 

No free fluid 

Liver -non palpable 

Spleen -non palpable 

CNS:

Conscious 

Normal speech 

No neck stiffness 

No kernings sign

INVESTIGATIONS :

09/08/2021

Biochemistry report :


Serum iron :

Blood grouping :



Hiv test :
Complete urine examination:

ECG report :
Ultrasound report 


Treatment given :
-Inj .LASIX 20mg /IU/BD
-Tab .NODOSIS 550mg PO/BD 
-Tab.SHELCAL /PO/OD 
-Tab .OROFER -XT/PO/OD
-Inj ERYTHROPOIETIN 
      4000 IU/S/Cweekly once 
-salt restriction <2g/day 
-fluid restriction <1lit/day  

Same treatment followed every week .


Diagnosis:CKD



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