45 YEAR MALE WITH SHORTNESS OF BREATH , LOSS OF APPETITE AND LOW BACK ACHE

45 YEAR MALE WITH SHORTNESS OF BREATH,LOSS OF APPETITE AND LOW BACK ACHE 

29/12/2021
4.43PM

A 45 year old male patient presented to the OPD with cheif complaints of shortness of breath GRADE II-III since 20 days,loss of appetite since 20 days and low back ache since 5 days


HISTORY OF PRESENTING ILLNESS 

45 year old male patient resident of nalgonda, mechanic by occupation. He was apparently asymptomatic 35 days back ,then he developed shortness of breath for which he went to the local hospital ,after further investigation diagnosed with chronic kidney disease and underwent dialysis. (4 times)

 
PAST HISTORY:

No similar complaints in the past 

MEDICAL HISTORY:

He is a known case of hypertension (since 1 month) ,using Tab NICARDIA 10mg
Not a known case of diabetes, tuberculosis, epilepsy, asthma.

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

Mixed diet
REDUCED APPETITE
Adequate sleep
Regular bowel and bladder movement

Patient consumes alcohol 1 quarter of whiskey per day since 12 years.Last consumption was 20 days back.

He is known smoker of 2 packets of cigarettes per day since 20 years.

GENERAL EXAMINATION:
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present(non pitting type)


VITALS:
Temperature-afebrile
Pulse rate-88 beats per minute 
Respiratory rate-18 breaths per minute 
Blood pressure-140/90mm hg
SpO2-99 at room air

SYSTEMIC EXAMINATION 
Cardiovascular system-S1 and S2 heard ,no murmurs heard

Respiratory system:
Dyspnoea-present
Breath sounds-vesicular breath sounds are normal

Central nervous system:
Patient was conscious,coherent and cooperative.
Speech was normal
No slurred speech
No Meningeal irritation signs

-No abnormality detected. 

REFLEXES:

Gait : normal 
                          INVESTIGATIONS
Usg report:


LAB INVESTIGATIONS :

Serology:
HBsAg,HIV1/2,HCV all are negative 

Renal function tests:
Urea-209mg/dl
Creatinine-13.6mg/dl
Uric acid-6.9mg/dl
Calcium-9.2mg/dl
Phosphorus-5.9mg/dl
Sodium-143mg/dl
Potassium-4.6mg/dl

Liver function test:
Total bilirubin:1.03mg/dl
Direct bilirubin:0.20mg/dl
SGOT-17 IU/L
SGPT-19 IU/L
Alkaline phosphate:97 IU/L
Total protein 6.6 gm/dl
Albumin:3.0 gm/dl
A/G ratio :0.83

Haemogram:
Haemoglobin-7 gm/dl
Total leucocyte count-4900 cells/cumm
Platelet count:2.49 lakhs/cu.mm

            

          COMPLETE URINE EXAMINATION 

  

Blood sugar random :83 mg/dl

      
                    ECG:
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on MHD 

Treatment :

1.Sali restriction < 2.4 Mg/ day
2.Fluid restriction <4 lit/day
3.Tab Nicardia  20 mg  PO/BD
4.Tab Nodosis 550mg PO/BD
5.Tab Oroder PO/BD
6.Tab Shercal 500mg PO/ OD
7.Inj Erythropoirtin 4000IU s/c weekly once
8.inj Iron sucrose 2Amp in 100 ml during dialysis 
9.Tab Lasix 90 mg /PO/TID


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