Case history-12

 A 53 OLD MALE WITH CKD

Date of admission:20/12/21

A 53 yr old male came to the opd with the chief complaint of pedal edema since 3yrs and c/o decreased urine output since 2yrs and k/c/o ckd on MHD since 3yrs .

HISTORY OF PRESENT ILLNESS: The patient was apparently asymptomatic  3yrs  back then he developed pedal edema insidious in onset ,gradually progressive ,pitting edema .

C/o decreased urine output  

No h/o chest pain ,palpations .

Daily routine(before ckd ):The patient wakes up in the morning by 5:30am and does his daily routine and have his breakfast (rice and curry )and goes to field and have his lunch at 1:30/2:00pm (rice and sambar ) and return to home by 4pm and relax and have dinner at 9pm and goes to bed by 10pm .

After ckd : The patient wakes up randomly based on his body functioning and does daily routine and have breakfast at 8:30 am (rice and curry )and take rest and have lunch at 1pm (rice and curry ) and stays at home and have dinner at 8:30pm (rice and curry ) and goes to bed by 9:30pm .

 HISTORY OF PAST ILLNESS:

K/c/o hypertension since 3yrs (on tab .NICARDIA 20 mg PO/BD )

Not a k/c/o diabetes mellitus ,asthma ,epilepsy.


TREATMENT HISTORY:

No diabetes,Hypertension siNce 3yrs on Tab .NICARDIA 20 mg ,noCAD ,asthma ,tuberculosis,antibiotics,hormones ,blood transfusion,surgeries.

PERSONAL HISTORY:

Married 

Occupation :farmer 

 appetite normal ,vegetarian

Regular bowel movement 

Micturation -normal  

No known allergies 

Addictions -no 

              

FAMILY HISTORY:

No history of diabetes,heart disease, stroke, asthma, tuberculosis,cancers .

Hypertension-yes 

General examination:

The patient is conscious, coherent, cooperative.

No Palar

No cyanosis 

No lymphadenopathy 

No malnutrition 

No dehydration 

clubbing yes 

No icterus 

edema -yes 

VITALS :

Temp :Afebrile 

Pulse rate:78/min 

Respiratory rate:18cpm 

Bp:180/90mm/hg 

Spo2-98%at 8L of o2

Grbs -115mg%

SYSTEMIC EXAMINATION:

CVS  :

No thrills 

No cardiac murmurs 

Cardiac sounds-s1,s2 heard 


RESPIRATORY SYSTEM :

No Dysponea

No wheeze 

Position of trachea-central 

Breath sounds-vesicular 


ABDOMEN:

Shape of abdomen-scaphoid 

No tenderness 

No palpable mass 

Hernial orifices-normal 

No free fluid 

No bruits 

Liver ,spleen-not palpable 

Bowel sounds -yes 

CNS:

Conscious 

Normal speech 

No neck stiffness 

No kernings signs 

Cranial nerves ,motor and sensory system,glasgow scale -normal .



PROVISIONAL DIAGNOSIS:

CKD ON MHD 

INVESTIGATIONS:

8/11/21












21/12/21



 
FINAL DIAGNOSIS:
CKD ON MHD 

TREATMENT GIVEN:
-Fluid and salt Restriction 
-Tab .NICARDIA 10 mg PO/BD 
-Tab .LASIX 40 mg PO/BD 
-Tab.NODOSIS 500mg PO/BD 
-Tab.SHELCAL -CT PO/OD 
-inj KRYTHROPOIETIN 4000IU S/C WEELKY ONCE .
-inj iron and sucrose 100 mg in 100 ml IV /OD .


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