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CASE OF 45YRS OLD MAN WITH CHRONIC KIDNEY DISEASE
10 June 2023
Greetings to one and all who are currently reading my blog. This is Jasmisri,eighth semester medical student
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A 45 yr old man a daily wage labourer by occupation resident of nalgonda came to OPD
CHIEF COMPLAINTS:-
Maintenance dialysis
HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 2 years back
Then one night he developed weakness of left upper limb and lower limb and unable to talk then he woke up his wife then he tried to walk for some time it relived after 2 hrs. He didn't sleep that night, next day morning again he had another episode, then he visited near by Nalagonda hospital then they diagnosed he had clot in brain by MRI and diagnosed that he had Hypertension and increased creatinine and he was on medication
After he stopped medication
2 months back he visited hospital for checkup SOB and Pedal edema then incresed creatinine was found out then after 1 week he was reffered to hyderabad hospital for dialysis 5 dialysis were done after 15 days he was reffered to KIMS narketpally for further dialysis now he had pedal edema and SOB
PAST HISTORY:-
Hypertension since 2 yr
N /k/c Diabetes Tuberculosis,Asthma
PERSONAL HISTORY
Diet-Mixed
Appetite-Decreased
Micturition-normal
Bowel movements-Normal
Sleep-Decreased
Addictions-Cigarette smoking 3-4packs per day stopped 2months back
Alcohol occasionally
Daily routine
2 yrs back -wake up at 5:30-6:00am
Eat tiffin
8am- work
2-3pm lunch box at work
8-9pm dinner
Sleep-9pm
Now-wake up at 5:30-6:00am
Eat tiffin
1pm lunch
Biscuits occasionally
8-9pm dinner
Sleep-9pm
FAMILY HISTORY:-
No significant history
GENERAL EXAMINATION:-
PALLOR
NO ICTERUS
NO CYANOSIS
NO CLUBBING
NO KOILONYCHIA
NO LYMPHADEONAPTHY
Pedal edema till knee
SYSTEMIC EXAMINATION:-
A. Cardiovascular system
S1 S2 HEARD
NO MURMURS.
B. Respiratory system
NVBS heard
BAE +
TRACHEA CENTRAL.
C. Per abdominal examination
SOFT
Scaphoid
Mild tenderness on left hypochondrium
D. Central nervous system:-
Conscious
Speech normal
Cranial nerve-NAD
Motor system-
Sensory system-NAD
Cerebellar system-NAD
No signs of meningial irritation/ meningitis
PROVISIONAL DIAGNOSIS:-
CHRONIC KIDNEY DISEASE ON MAINTENANCE DIALYSIS
INVESTIGATIONS:-
TREATMENT:-
08-06-23
Rx
TAB LASIX PO / BD
TAB NICARDIA 100mg PO / BD
TAB ARKAMINE 0.1mg PO /TID
TAB OROFOR ×T PO / BD
TAB SHELCAL PO / OD
CAP URISED
INJ EPO 4000 IV SC / twice weekly
TAB ECOSPIRIN AV 75 / 10 / PO
TAB NODOSIS 500mg PO / BD
TAB SEVELAMER 400mg PO / TID
09-06-23
Rx
TAB LASIX PO / BD
TAB NICARDIA 100mg PO / BD
TAB ARKAMINE 0.1mg PO /TID
TAB OROFOR ×T PO / BD
TAB SHELCAL PO / OD
CAP URISED
INJ EPO 4000 IV SC / twice weekly
TAB ECOSPIRIN AV 75 / 10 / PO
TAB NODOSIS 500mg PO / BD
TAB SEVELAMER 400mg PO / TID
10-06-23
Rx
TAB LASIX PO / BD
TAB NICARDIA 100mg PO / BD
TAB ARKAMINE 0.1mg PO /TID
TAB OROFOR ×T PO / BD
TAB SHELCAL PO / OD
CAP URISED
INJ EPO 4000 IV SC / twice weekly
TAB ECOSPIRIN AV 75 / 10 / PO
TAB NODOSIS 500mg PO / BD
TAB SEVELAMER 400mg PO / TID
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