General medicine case-2
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Date of admission : 06-09-2021
A 28yr old male resident of miryalguda , employee by occupation came to our hospital with complaints of weakness and decreased urine output on 19-06-2021 and got diagnosed as AKI .
History of present illness:
Patient was asymptomatic till April this year
Patient had history of weight loss(10kgs) since 1 and 1/2 month and decreased appetite and decreased urine output and generalized itching . So he visited global hospital where they diagnosed with renal failure and hypertension.
Four sessions of hemodialysis were done here on AKI
Later got readmitted on 06-07-21 on CKD on MHD. 10 sessions of hemodialysis were done.
Currently patient has no history of pedal edema ,SOB and decreased urine output.
HISTORY OF PAST ILLNESS
Patient has no history of pedal edema and SOB.
Patient has known history of hypertension since 4months .
No history of any surgeries.
No history of diabetes,fever.
No history of blood transfusions.
PERSONAL HISTORY
Normal appetite
Bowel regular
Micturition - normal
Patient was occasional alcoholic and non- smoker.
FAMILY HISTORY
No history of Diabetes, hypertension
No history of cancer.
No history of hereditary symptoms.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
There are no signs of cyanosis, lymphadenopathy, clubbing,icterus.
Vitals
Temperature: afebrile
Pulse rate : 92bpm
B.p : 140/90
Respiratory rate : normal
SYSTEMIC EXAMINATION
Cardiovascular system
Thrills : No
Cardiac sounds : S1 and S2 heard
RESPIRATORY SYSTEM
No dyspnea
No wheezing
Position of trachea : central
Breath sounds: vesicular
Adventitious sounds - no
ABDOMEN
Abdomen distended,soft and non tender
Bowel sounds heard
Palpable mass - no
Free fluid - no
CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech : normal
no signs of meningeal irritation
Sensory and motor reflexes- intact
PROVISIONAL DIAGNOSIS
CKD on MHD
Known case of hypertension
INVESTIGATIONS
TREATMENT
T. LASIX 20mg/PO/BD
T. NICARDIA -RETARD 20mg/PO/BD
T. NODOSIS 500mg/PO/TID
T. OROFER - XT/PO/BD
T.SHELCAL 500mg/PO/OD
T.ALPHA D3 0.25mg/PO/OD
INJ. ERYTHROPOIETIN -4000IU
S/C WEEKLY ONCE
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