General medicine case
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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 complaint: 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 HISTROY :
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
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
INVESTIGATIONS :
ECG :
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