Final GM-Short case

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Date of admission:07/02/2022

A 39 year old male came to OPD with a chief complaint of SOB,Pedal edema and decreased urine output since 4 months.

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 6 years back and on one day he had an onset of fever which lasted for 10 days for which he went to a local hospital for which he was prescribed medicines.After taking medication the patient complained that he had severe back ache and he passed out unconscious while urination.He was admitted in the hospital and he was said that his creatinine levels were high and he was referred to our hospital for Hemodialysis.He had sessions of Hemodialysis done and is on conservative management for 4 years.

4 months back,the patient came to casuality with a chief complaint of SOB,Pedal edema and decreased urine output.

PAST HISTORY:

K/C/O Hypertension since 4 months and is on TAB NICARDIA 20mg BD.

No H/O DM

No H/O Asthma

No H/O Epilepsy 

PERSONAL HISTORY:

Diet-Mixed

Appetite-Decreased

Sleep-Inadequate

Decreased urine output

Bowel movements-Regular and loose stools were observed with foul smell.

Smoking- Smokes 3-4 cigarettes per day

Alcohol-Stopped drinking since 2 years.

FAMILY HISTORY:

No significant family history.

TREATMENT HISTORY:

The patient is on TAB NICARDIA 20mg BD for hypertension since 4 months.

No known drug allergies.

GENERAL EXAMINATION:

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

Built: The patient looks lean and is unable to walk without support.

Nourishment: Malnourished 

Icterus-Present

Pedal edema-Pitting type is present.

-No pallor

-No clubbing

-No cyanosis

-No generalized lymphadenopathy

VITALS:

TEMP. - AFEBRILE

PR - 91 BPM

RR - 18 CPM

BP - 140/70 mmHg

SpO2 - 98% AT RA

GRBS - 121 mg/dL

SYSTEMIC EXAMINATION:

CVS- S1,S2 HEARD

RS- BAE +

CNS- NAD

P/A - DISTENDED ABDOMEN.UMBILICAL HERNIA IS OBSERVED.ON PERCUSSION,SHIFTING DULLNESS IS OBSERVED.

INVESTIGATIONS:

COMPLETE BLOOD PICTURE (CBP):

HAEMOGLOBIN-11.1gm/dl

TOTAL COUNT-8200 cells/cumm

NEUTROPHILS-80%

LYMPHOCYTES-11%

EOSINOPHILS-03%

MONOCYTES-06%

BASOPHILS-0%

PLATELET COUNT-2.41

SMEAR-Normocytic,Normochromic

SERUM CREATININE-5.6mg/dl

BLOOD UREA-72mg/dl

LIVER FUNCTION TEST (LFT) 

Total Bilurubin-1.18mg/dl

Direct Bilirubin-0.46mg/dl

SGOT(AST)-16 IU/L

SGPT(ALT)-09 IU/L

ALKALINE PHOSPHATE-393 IU/L

TOTAL PROTEINS-6.8 gm/dl

ALBUMIN-4.0 gm/dl

AVG RATIO-1.45

PROVISIONAL DIAGNOSIS:

?CKD On MHD

TREATMENT GIVEN:

1. FLUID RESTRICTION <2 L/DAY

2. SALT RESTRICTION <2 GM/DAY

3. TAB. LASIX 40 MG PO BD

4. TAB. NICARDIA 20 MG PO BD

5. TAB. OROFER XT 1 TAB PO OD

6. TAB. SHELCAL XT 1 TAB PO OD

8. INJ. ERYTHROPOIETIN 4000 IU S/C WEEKLY ONCE

9. INJ. IRON SUCROSE 1 AMP IN 100 ML NS DURING DIALYSIS

10. VITALS MONITORING 6TH HRLY, I/O CHARTING

10'SESSIONS OF DIALYSIS DONE.