General Medicine Case 4

 A 60 YEAR OLD MALE PATIENT CASE 

October 28, 2021

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Date of admission: 21 October 2021

A 60 yr old male who is a farmer by occupation came to the OPD for the dialysis diagnosed as kidney failure 1 1/2 back . He went to local hospital and was diagnosed with renal failure( serum creatinine 3mg/dl

CHIEF COMPLAINTS : 

 patient complains of shortness of breath, sleeplessness, swelling of limbs.

HISTORY OF PRESENT ILLNESS :

• Pedal edema 

• Anorexia 

• Fever 

• Dyspepsia 

•  Insomnia 

• Serum creatinine levels - increased (2 mg /dl) 

• Decreased urine output 

Presently on dialysis on MHD 

HISTORY OF PAST ILLNESS : 

• On dialysis since 1 and half year 

• K/h/o Hypertension sice 6 years 

• No h/o DM 

• No tuberculosis

• No asthama 

• No Lymphadenopathy

• No h/o trauma 

• No h/o previous surgery 

• No h/o any previous radiation exposure 

PERSONAL HISTORY  : 

• Patient is unable to walk 

• Appetite normal 

• Mixed diet 

• Sleep adequate 

• Urine output decreased

• Regular bowel movements 

• No known allergies 

• No addictions 

FAMILY HISTORY : 

• No history of similar complaints seen in the family 

TREATMENT HISTORY : 

•On dialysis from 21/10/2021 

• Visits weekly twice for dialysis

GENERAL EXAMINATION : 

• Patient is coperative, coherent and conscious.

• Pallor - present 

• No clubbing 

• No icterus

• No cyanosis 

• No malnutrition 

• No dehydration 

• Temperature- 98.4 °F

• Pulse rate - 84 per min 

• Bp - 130/70 mm hg 

• Sp02 - 98 %

• Grbs - 136 mg % 

SYSTEMIC EXAMINATION : 

CVS : 

No thrills 

Cardiac sounds S1,S2 normal 

No cardiac murmurs 

RESPIRATORY SYSTEM: 

No wheeze 

Position of trachea central 

ABDOMEN : 

Shape of abdomen : seaphoid 

Liver non palpable 

Spleen non palpable 

Bowel sounds present 

CNS : 

Coordinated movements 

PROVISIONAL DIAGNOSIS : 

CKD on MHD 

INVESTIGATIONS : 

  ECG : 

TREATMENT: 

Fluid restriction <1.5 L/ day 

Salt restriction <2g/day 

Tab. Lasix 40 mg 

Tab . Nodosis 500 mg 

Tab . Bio D 3 0.25 mg 

Tab. Shellcal CT 500 mg