4.Chronic kidney disease
CASE:- Chronic kidney disease
CheIf complaint -
A 40 year old man , is a farmer by occupation came with the complaints of
Pedal edema since 3 months , along with facial puffiness , Shortness of breathe ( Grade 4) and
Decreased urine output since 3 months
HISTORY OF PAST ILLNESS:-
Not a known case of hypertension, diabetes, asthma, epilepsy, tuberculosis.
PERSONAL HISTORY:-
Patient takes mixed diet, normal appetite
sleep adequate(sleeps about 6-7 hours at night, wakes up early in the morning for work).
Bowel and bladder habits are regular.
No addictions.
GENERAL EXAMINATION:-
On examination:
Patient is conscious, coherent
Vitals-
Temp: afebrile
PR: 84. bpm
BP: 130/70 mm hg
RR: 24 cpm
GRBS: 136 mg /dl
SPo2 - 98%
No Pallor
No Icterus
No signs of cyanosis, clubbing, koilonychia.
Pedal edema is present .
PER ABDOMEN: soft, non tender
CVS: S1S2 heard
RS: BAE +, NVBS+
CNS: NAD
Investigations:
Hb: 8.0 gm/ dl
Tlc: 16,800 cells/mm3
Platelets: 4.8 lakhs/mm3
Total bilirubin: 6.9
Direct bilirubin: 2.85
GENERAL EXAMINATION:-
Treatment -
Dialysis started on 15/10/21
Fluid restriction - < 1.5 litres/ day
Salt restriction - <2 g/day
Tab . Lasix 40mg BD
Tab. Nodosis 500 mg BD
Tab . Shelcal CT OD
Tab BIO D3 0.24 mg OD
Tab .Orfer XT OD
Tab . Erythromycin 4000IU /SC
Cetrizine TID
Syp.Benadryl TID
2/9/21 -
Dialysis started on 15/10/21
Fluid restriction - < 1.5 litres/ day
Salt restriction - <2 g/day
Tab . Lasix 40mg BD
Tab. Nodosis 500 mg BD
Tab . Shelcal CT OD
Tab BIO D3 0.24 mg OD
Tab .Orfer XT OD
Tab . Erythromycin 4000IU /SC
28/10/21
Tab . Lasix 40mg BD
Tab. Nodosis 500 mg BD
Tab . Shelcal CT OD
Tab BIO D3 0.24 mg OD
Tab .Orfer XT OD
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