Case history -1

 August 10, 2021

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Date of admission: 04/08/2021

A 45 year old man presented to the OPD with chief complaints of swelling of both the legs and shortness of breath since 2 months

History of present illness:

Patient was apparently asymptomatic 4 months back then he complained of swelling below the knee

The swelling was gradually progressive in nature, pitting type. 

The swelling was associated with pain. Patient also complained shortness of breath. 

6 days back patient presented to the casuality with swelling in the legs and shortness of breath. 

Patient has undergone 3 dialysis units till 10/8/21

Past history:

Patient visited the nearest hospital, and was diagnosed with kidney problem, and was suggested on medication

There is no history of surgeries in the past.

No history of DM, asthma, epilepsy

Patient is a known case of hypertension since 1 year. 

Personal history:

Appetite-normal

Bladder and bowel movement- normal

Sleep- inadequate

Addiction- patient consumes alcohol since 20 years

Family history:

No history of thyroid disorder, asthma, CAD in the past

Patient's mother has a history of hypertension and diabetes

Patient's father has a history of hypertension

General examination:

Patient is conscious, coherent and co- operative

No pallor, no clubbing, no lymphanedopathy

Paedal edema is present. 

Vitals:

Temperature: 37.5 degree Celsius

Pulse rate- 80b/m

Respiratory rate- 16 breaths

BP- 110/80 mm Hg

Systemic examination:

CARDIOVASCULAR SYSTEM:

Chest wall is bilaterally symmetrical

No precordial bulge

No visible pulsations, engorged veins, scars, sinuses

Palpation:

Apex beat: felt in the left 5 th intercostal space in mid clavicular line

Auscultation: S1, 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. 

INVESTIGATIONS:

LFT:

Total bilirubin- O. 81mg/dl

Direct bilirubin- 0.20mg/dl

SGOT-12 IU/L

SGPT-10 IU/L

Alkaline phosphatase=# 283IU/L

Total protein=# 6.3gm/l

Albumin- 3.6 gm/l

Phosphorus=#6.0mg/dl

Calcium= 9.4mg/dl

Serum iron= 72 microg/dl

RBS= 109mg/dl

Blood urea= # 97mg/dl

Serum creatinine= # 7.5mg/dl

SERUM ELECTROLYTES:

Sodium= 137mEq/L

Potassium= 4.4 mEq/L

Chloride= 99 mEq/L

PROVISIONAL DIAGNOSIS:

Chronic Renal failure. 

TREATMENT:

Since patient has Hb 6.6gm/dl , he undervent blood transfusion (PRBC) on 8/8/21

1. Tab. NICARDIA R 6 TARD 20 mg PO/BD

2. Tab. NODOSIS 500 mg PO/ OD

3. Tab. OROFER XT PO/BD

4. Tab. SHELAC AC CT PO/ BD

5. Inj. ERYTHROPOITIN 4000 IO

S/C weekly twice

6. Inj. IRON SUCROSE 10 mp in 50 ml

NS/ IV/Weekly once

7. Fluid restriction < 1.5 L/day

8. Salt restriction< 4 gm/day

9. T. LASIX 40 mg PO/BD