General medicine case

August 09, 2021

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Date of admission : 05-08-2021

A 50 years old man presented to the OPD with chief complaints of shortness of breath, and swelling of both the legs from past one month.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1 month back.

Then he complained of bilateral pedal edema which was gradually progressive pitting type. He also complained of shortness of breath and decreased urine output. Then they went to nearest medical care and diagnosed with kidney problem for which he advised to undergo dialysis.

5 sessions of dialysis have been done till 23-07-2021.

5 days back patient presented to the casualty with swelling in the legs and shortness of breath and undergone 4 dialysis.

HISTORY OF PAST ILLNESS

Patient is a known case of DM for past 10 years.

Patient is known case of HTN for 4 years.

Patient is a known case of CKD on MHD.

Patient has undergone Epididymectomy surgery 5 years back.

Not a known case of asthma, epilepsy, TTS.

No history of surgeries and blood transfusions in the past .

PERSONAL HISTORY

Decrease appetite 

Micturition - abnormal

Alcohol addiction - regular

Sleep inadequate

FAMILY HISTORY

No similar complaints in the family.

No history of CVA,CAD,asthma and thyroid disorder in the family.

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative.

There is pedal edema 

No cyanosis, clubbing , lymphadenopathy.

VITALS 

Temperature : afebrile 

Pulse rate : 98 bpm

Respiratory rate : 8cpm 

B.P : 160/100 

Spo2 at room air : 98%

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM 

Thrills - No

Cardiac sounds - S1 and S2 heard 

RESPIRATORY SYSTEM

Dyspnea - present

No wheezing

Position of trachea - central 

Bilateral air entry +

Normal vesicular breath sounds - heard  

ABDOMEN

Shape of abdomen - obese

Hernial orifices - normal

No palpable mass or free fluid 

Liver - Not palpable 

Spleen - Not palpable

CENTRAL NERVOUS SYSTEM

Patient is conscious

Speech - normal 

No signs of meningeal irritation

Sensory and motor reflexes - intact 

PROVISIONAL DIAGNOSIS

Chronic kidney disease (CKD) on maintenance hemodialysis.

INVESTIGATION

RFT 

Urea - #94 mg/dl 

Creatinine - #3.0 mg/dl 

Uric acid - 6.9 mg/dl 

Calcium - 9.6 mg/dl 

Phosphorus - 4.3 mg/dl up

Sodium - #135 mEq/L 

Potassium - 3.5 mEq/L 

Chloride - 101mEq/L 

Fasting blood sugar : #193mg/dl 

Post lunch blood sugar : #219mg/dl 

Serum iron : 71ug/dl 

Glycated haemoglobin HbA1c : 7.1% 

Hemogram : 

Haemoglobin : #9.8gm/dl 

Total count : 8700 cells/cumm 

Neutrophils : 73% 

Lymphocytes : 18% 

Monocytes : 05% 

Basophils : 0% 

PCV : #26.7 vol% 

MCV : #74.6 fl 

MCH : 27.4 pg 

MCHC : #36.7% 

RBC count : 3.58 millions/cumm 

Platelet count : 3.02 lakhs/cumm

Smear 

RBC : Microcytic hypochromic 

WBC : within normal limit 

Platelets : adequate 

Hemoparasites : no hemoparasites seen

Impression : Microcytic hypochromic anemia

TREATMENT

INJ. LASIX 40 mg IV/BD 

Tab. NICARDIA 10mg PO/TID 

Tab. OROFER - XT PO/BD 

INJ. ERYTHROPOIETIN 4000IU S/C once weekly 

Tab. SHELCAL 500 mg PO/OD 

Tab. NODOSIS 550mg PO/BD 

FLUID RESTRICTION UP TO 1Lit/day 

SALT RESTRICTION<2GM/DAY