General medicine Case-1

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                                                                                Date of admission:2/8/21

A 45 years old man who was a farmer presented to the OPD with cheif complaints of Swelling of both the legs and Shortness of breath from past 2 month's.  

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 4months back.

Then he complained of Bilateral Pedal Edema which was gradually progressive,pitting type,below the knee.                                            He also complained Shortness of breath.            ( Grade-2 )  and pain in the legs. Then they went to nearest medical care and daignosed with kidney problem and was started on medication.

6days back patient presented to the casuality with swelling in the legs and shortness of breath for which he adviced to undergo dialysis.

3 dialysis units have been done till 10/8/21

HISTORY OF PAST ILLNESS

Patient is a known case of HTN from past 1 year .

Not a known case of DM,TTS,Asthama and Epilepsy.

No history of surgeries and blood transfusions in the past 

FAMILY HISTORY 

Patient's father was known case of BP 

Patient's mother was a known case of Sugar and BP 

No history of CVA,CAD, Asthama and Thyroid disorder in the family.

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative

There is Pedal Edema 

No pallor,clubbing,koilonychia and lymphadenopathy 

VITALS 

Temperature: 37.5 ⁰c

Pulse rate: 80 b/m

Respiratory rate: 16breathes

BP : 110/80 mmHg 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Chest wall is bilaterally symmetrical

No precordial bulge 

No visible pulsations, engorged veins,scars and sinues.

PALPATION

Apex beat : felt in the left 5th intercostal space in mid clavicular line.

AUSCULTATION

S1 and S2 heard

RESPIRATORY SYSTEM

Position of trachea - central

Bilateral air entry : +

Normal vesicular breath sounds - heard 

PER ABDOMEN

Abdomen distended,soft and non tender.

Bowel sounds heard.

No palpable mass or free fluid.

CENTRAL NERVOUS SYSTEM

Patient is conscious.

Speech : normal 

No signs of meningeal irritation 

Sensory and motor reflexes: intact 

PROVISIONAL DIAGNOSIS 

Chronic renal failure

INVESTIGATIONS 

LFT : 

Total bilirubin: 0.81 mg/dl 

Direct bilirubin: 0.20 mg/dl 

SGOT: 12 IU/L 

SGPT: 10 IU/L 

Alkaline phosphatase: #283 IU/L 

Total proteins: # 6.3 gm/l 

Albumin: 3.6 gm/l 

Phosphorus: #6.0 mg/dl 

Calcium: 9.4 mg/dl 

Serum iron 72 micro g/dl  

RBS : 109 mg/dl 

Blood urea : # 97 mg/dl 

Serum creatinine : # 7.5 mg/dl 

SERUM ELECTROLYTES 

Sodium: 137 mEq/L 

Potassium: 4.4 mEq/L 

Chloride : 99 mEq/L 

      CBP

    CUE

     ECG  

    TREATMENT 

   Since patient has Hb 6.6 gm/dl he undervent      blood transfusion (PRBC) on 8/8/21 

    1. Tab. NICARDIA R 6 TARD 20mg PO/BD

    2. Tab. NODOSIS 500mg PO/OD 

    3. Tab. OROFER XT PO/BD 

    4. Tab. SHELAC AC CT PO/BD 

    5. Inj. ERYTHROPOIETIN 4000 IO.    

          S/C weekly twice

    6. Inj. IRON SUCROSE 10mp in 50ml        

          NS/IV/ Weekly once.  

    7. Fluid restriction < 1.5 L/day.   

    8. Salt restriction < 4 gm/day 

    9. T. LASIX 40 mg PO/BD