General Medicine Case 3

25.C.Ruchitha Reddy.

 September 26,2021.

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Date of Admission: September 20 2021.

A 60 yr old Male came to OPD with chief complaints of;

-pedal edema

-Facial Puffiness

- decreased urine output,

-SOB since 10 days

HISTORY OF PRESENT ILLNESS;

Patient was asymptomatic 2 months back then patient complaints of Generalized weakness, pedal edema,Facial puffiness, decreased urine output.Then He consulted local doctor then they referred him to go to NIMS,there he was diagnosed with CKD..

He was undergoing Dialysis(6)since then..

HISTORY OF PAST ILLNESS;

-Hypertension since 2 months.

-There is no History of  Tuberculosis, Epilepsy,Asthma, Diabetes.

-There is no History of any Surgeries.

PERSONAL HISTORY;

-Diet-Mixed

-Appetite- Lost

-Sleep-Disturbed Sleep

-Bowel and Bladder movements - regular

-No Addictions

-No h/o known allergies.

FAMILY HISTORY;

There is no family history of such kind of problems..

GENERAL EXAMINATION; 

-Patient is conscious, coherent, cooperative.

-Ectomorphic built

-Slightly Malnourished.

-patient is considerably pallor

-Pitting type of edema is seen

-There is Facial puffiness

-No icterus

-No Cyanosis

-No clubbing of feet

-No Lymphadenopathy

VITALS;

-Temperature-Afebrile

-Pulse rate- 92 beats/min on palpation

-Respiratory rate-18cycles/min

-BP-140/80mm Hg

-Spo2-98%

-GRBS-147 mg%

SYSTEMIC EXAMINATION;

CVS;

-s1,s2 hears,No murmurs.

Respiratory system;

-Position of trachea- Central

-Normal vesicular Breath Sounds -Heard

-No added sounds

Abdomen;

- on palpation,there is No abdominal tenderness

CNS;

-Patient is Conscious

-Speech-Normal

-Mortar and sensory system Normal.

PROVISIONAL DIAGNOSIS/FINAL DIAGNOSIS;

CKD on maintenance of Hemodialysis.

INVESTIGATIONS;

                        HEMOGRAM;

     Hemoglobin-7.3 gm/dl

     Total Count-14,500 cells/cumm

      Neutrophils-91%

      Lymphocytes-4%

      Eosinophils-2%

      Monocytes-3%

      Basophils-00%

      PCV-20.4vol%

     M.C.V-89.1fl

     M.C.H-31.9pg

     M.C.H.C-35.8%

     RDW-CV-15.2%

     RDW-SD-50.5fl

     RBC Count-2.29 millions/cumm

     Platelet Count-1.97lakhs/cumm

Smear;

    RBC- Normocytic normochromic Anemia

    WBC-Increased in count

    Platelets -Adequate

    Hemoparasites-No Heamoparasites seen

   Impression- Normocytic normochromic Anemia with       neutrophilic leukocytosis blood Picture

           BLOOD GROUPING AND RH TYPE;

     B+

                       SERUM IRON

                        82ug/dl

-Blood Sugar -Random;140mg/dl 

                            RFT;

    Urea- 64 mg/dl

    Creatinine- 5.7 mg/dl 

     Uric Acid-3.6 mg/dl  

     Calcium-10mg/dl

     Phosphorus-2.8mg/dl

     Sodium-136mEq/L

     Potassium-3.7mEq/L

     Chloride-92mEq/L

                Liver Function Tests;

        Total Bilurubin-0.71mg/dl

         Direct Bilurubin-0.20mg/dl

         SGOT(AST)-40IU/L

       Alkaline Phosphate-333IU/L

        Total proteins-6 gm/dl

       Albumin-3.5gm/dl

       A/G ratio-1.48 gm /dl.

Treatment;

       TAB. SHELCAL-500mg OD

       TAB. NODOSIS-500mg BD

       TAB. OROFER-XT OD

       TAB. LASIX-40mg OD

      TAB.PANTOP-40 mg OD.