General medicine case history 4
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A 65 year old male who is builder by occupation presented our causality with cheif complaint of shortness of breath and pedal edema since 20days and gradual weight loss
Date of admission :-30/12/2021
History of present illness:-
Daily routine of the patient:-
Patient wakes up at 6am daily everyday completes his breakfast by 7:00am and reports his work by 9pm completes his work by evening 5pm completes his dinner.by 9pm and goes to bed by 10pm
Patient was apparently asymptomatic 20days back and developed shortness of breath since 20days, pedal edema and weight loss
Patient is anemic so had blood transfusions of 2 units
He completed dialysis of 6 cycles since then
Not associated with any other symptoms like fever,vomiting,nausea,headache,cough,cold
In the past i.e before visiting our hospital he went to the local hospital due to shortness of breath then they did several tests and confirmed it as kidney failure and immediately he rushed to our hospital the next day.
Past history :-
Patient had no similar complaints in the past
Patient had an accident before 14years then he had a spinal cord injury and developed severe joint pain and back ache since then
Patient suffers from hypertension since 2months
No h/o diabetes
No h/o epilepsy
No h/o lymphadenopathy
No h/o asthma
No h/o tb
Personal history :
Appetite : abnormal
Diet : vegetarian
Bowel : regular
Bladder : regular
Sleep : inadequate
Addictions : 14 years back he is chronic smoker but he quitted smoking after he suffered from accident
He even had a habit of alcohol occasionally
Family history :-
No similar complaints in the family
Drug history :-
No allergy to known drugs
General examination:-
Patient of concious,coherent and cooperative
Pallor is present
Pedel edema is present
No cyanosis
No lymphadenopathy
No icterus
No clubbing
Vitals :
Temperature: 98.5f
Pulse :99/min
Respiratory rate : 18/min
Bp : 140/90 mm/hg
Systemic examination :-
CVS:
S1 and S2 are heard
No mummers are heard
No thrills
Respiratory system :
No dyspnoea
No wheeze
Position of trachea :central
Abdomen :
Shape of abdomen :scaphoid
No tenderness
No palpable mass
Cns:
Patient is conscious
Speech is normal
No neck stiffness
Provisional diagnosis:
Ckd on mhd
Investigations:
Ultrasound:
Treatment :
Inj lasix 40mg /Iv/tidTab nodosin 55 mg /po/boTab shellal 500mg /po/odTab drofer-Xt /po/od Salt restriction <2.4gm/day Fluid restriction <1lit/day Tab nicardia 20mg /po/bd Inj erythropoietin 4000IU weekly once
Treatment :
Inj lasix 40mg /Iv/tid
Tab nodosin 55 mg /po/bo
Tab shellal 500mg /po/od
Tab drofer-Xt /po/od
Salt restriction <2.4gm/day
Fluid restriction <1lit/day
Tab nicardia 20mg /po/bd
Inj erythropoietin 4000IU weekly once
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