General medicine Case-3
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Date of admission :- 30/8/21
CHIEF COMPLAINTS:-
A 45 years old male resident of Suryapet, Mechanic by occupation, presented to the OPD with the chief complaints of pedal edema, decreased urine output and shortness of breath ( grade -2) from past 6 months.
Patient was on hemodialysis maintanence till August 1st and then went to NIMS for peritoneal dialysis.
HISTORY OF PRESENT ILLNESS:-
2 years back patient noticed puffiness of the face, bilateral pedal edema then he visited hospital in Khammam and was on medication.
Patient was apparently asymptomatic 6months back then he developed pedal edema which is gradually progressive in nature associated with decreased urine output.
Total number of dialysis till date 6/9/21 :-. 25-30 dialysis.
HISTORY OF PAST ILLNESS:-
Patient was a known case of Diabetes from past 10 years and on Insulin therapy from 2 years.
Patient was a known case of HTN from 1 year
Patient was a known history of Blood transfusion with 2 units ,2 months back.
No H/O any surgeries .
No H/O any fever.
No H/O of any associated symptoms.
No H/O epilepsy and bronchial asthama.
PERSONAL HISTORY:-
Diet : Mixed
Appetite: Normal
Sleep: inadequate
Bowel and bladder moments are irregular from past 4 days.
Patient consumes alcohol occassionally and stopped 3 years back.
No habit of smoking.
FAMILY HISTORY :-
No H/O of cancer.
No H/O of hereditary symptoms.
GENERAL EXAMINATION:-
Patient is conscious, coherent and cooperative.
No cyanosis, clubbing, koilonychia and lymphadenopathy.
VITALS :-
Temperature : afebrile
Pulse rate: 86bpm
Respiratory rate:- 17 breaths
Bp : 140/100 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
PROVISINAL DIAGNOSIS:-
Chronic renal failure.
RFT
CBP
TREATMENT:-
1) Inj. LASIX- 40mg IV/TID
2) T.NODOSIS -500mg PO/BD
3) T. OROFER XT PO/BD
4) T. SHELCAL 500mg PO/OD
5) Inj. ERYTHROPOIETIN 4000 IU
S/C Weekly twice
6) Inj. Iron Sucrose one amp
in 100 ml NS/IV/ weekly once
7) Inj. HAI S/C acc to GRBS
8) Fluid restriction less than 1.5 lit per day
Salt restriction less than 4gm per day
9) T. CILINIDIPINE 10mg PO/OD
10) T. ARKAMINE 0.1 mg PO/BD
11) T. CARVEDILOL 6.25 mg PO/OD
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