Case history 06

 Date of admission: 13- oct -2021

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A 32 year old male came to OPD with chief complaints of pedal edema, low urine output and shortness of breath since past 4 days.

HISTORY OF PRESENT ILLNESS:

Patient is a autodriver by profession. He used to wake up 5 in the morning, working from morning 6 a.m to 8 pm. His daily routine comprise of dropping of children to school. He used to have an occasional drink with his friends.

Patient was asymptomatic 7 months back, 

7 months ago, the patient suffers from headache, dizziness, blurring of vision and was went to local hospital and was diagnosed with hypertension. Patient was started using a drug Telma.

6months ago, patient went to hospital for decreased urine output. There he was diagnosed with high creatine level and was referred to KIMS for dialysis.

4months ago, patient develop severe back pain which is dragging type. He took over the counter drug for relieve. The pain subsided on medication.

1month ago, patient suffers from pedal edema on left leg which is pitting type. Both legs are not equally involved as there is more marked edema on right leg than left.

Decreased urine output since 10days with burning micturition.

PAST HISTORY:

patient is a known case of hypertension,  TB and diabetes mellitus 

FAMILY HISTORY:

There is a history of DM and hypertension in the family.

PERSONAL HISTORY:

Diet: mixed

Apetite: normal

Bowel: reduced

Micturition : burning with pain

Socio- economic: poor

Patient used to consume alcohol occasionally during gatherings.

GENERAL EXAMINATION:

patient was conscious, coherent and cooperative and well oriented to time, place and person.

No pallor, icterus cyanosis and clubbing  

Generalised anasarca is present.

VITALS:

Temp:afebrile

B.p:150/80

Respiratory rate:19 /min

PR:98 bpm

Spo2 : 98% at room temperature

GRBS: 127mg%

SYSTEMIC EXAMINATION:

CVS

S1 and S2 are heard

no thrills and no murmurs

Respiratory 

vesicular breath sounds heard

trachea is in central position

no wheezing

no dyspnoea

on 7th october the patients Oxygen saturation was dropping and reached 40% , so since then the patient has been given humidified oxygen

on 8th october JVP was seen prominently and Rhonchi was heard , the patient was put on nebulization with budecort 

Abdomen

obese shaped abdomen

no tenderness

no palpable mass

no hernial orifices

no free fluid

liver and spleen are not palpable

bowel sounds are heard

CNS

Conscious and normal speech

normal gait

crainal nerves are normal

sensory system is normal

motor system is normal

Reflexes

             right.     left

biceps     +2         +2

triceps.    +2.        +2

supinator +2         +2

knee        +2          +2

ankle.       +2         +2

INVESTIGATIONS

MRI

Ultrasound report 

 

Ultrasound report 

RFT

Complete blood picture

LFT

Blood sugar random

RFT

Complete blood picture

RFT

RFT

Hemogram

C reactive protein

ESR

Hemogram

ECG

PROVISIONAL DIAGNOSIS:

  Chronic kidney disease on MHD secondary to Hypertensive nephropathy

TREATMENT : 

On from 05 -10- 2021 to 12-10-2021

Fluid restriction <1L/day

Salt restriction <2.4L/day

T.Lasix 40mg PO/BD

T.Nicardia 20mg PO/TID

T.Arkamine 0.1 mg PO/BD

T.Shelcal CT po/od 

T.Nodosis 500 mg 

T.Met XL 50 mg po/od 

INJ erythropoietin 4000 units weekly once 

BP monitoring

On 13th october.

Patient was discharged and was asked to come for dialysis.