General medicine case 3
Date of admission :24/06/21
A 28 year old male who works as a private employee in shopping mall.he admitted with acute weakness and urine output decrease since 5 months .
Cheif complaint:
Patient was asymptomatic till April this year .
Patient was admitted with decrease output and got diagnosed as acute glomerular nephritis. A 4 sessions of hemodialysis are done later got admitted on ckd on mhd . Then 10 session hemodialysis done.
History of present illness
Weight loss since 1mon . Decrease in appetite.
Visited golbule hospital where they said he had renal problem.
History of past illnesses:
There are no similar complaints in the past.
Hypertension is present.
No diabetes mellitus.
No asthma
No TB
No epilepsy
No previous surgery
Personal history:
Diet:mixed
Appetite:normal
Bowel:normal
Bladder:normal
Occasional alchohol habbit .no smoking habit.
Family history:
There are no similar complaints in family.
Drug history:
No allergy to known drugs.
General examination:
Pallor is present
No cyanosis
No lymphadenopathy
No dehydration
No malnutrition
No icterus
No clubbing
No pedal edema
Temperature :- 97°F
Pulse rate:- 80/min
Respiration rate :- 16 /min
Blood pressure:- 140/70 mm Hg
Systemic examination:-
Cvs
S1 and S2 sounds are heard.
Respiratory system:
Position of trachea:central
No dysponea
Breath sounds:vesicular
Abdomen:
Abdomen is scaphoid,tenderness is not present, no palpable mass is present.
CNS:
Patient is conscious
Speech is normal
No neck stiffness
Provisional diagnosis:
Ckd on mhd
CBP;
Hb-7.0gm/dl
Total count-7100cells/cum
Neutophils-70%
Lymphocytes-20%
Eosinophils-5%
Monocytes-5%
Basophils-00%
Platelet -2.17lakh/cu mm
Serum iron -62ug/dl
RFT;
Urea-173mg/dl
Creatinine-9.3mg/dl
Uric acid- 8.2 mg/dl
Calcium-10mg/dL
Phosphorus-6.5 mg/dL
Sodium-136mEq/L
Potassium-6.1mEq/L
Chloride-104mEq/L
ECG:
Treatment:
T lasix 20mg/ po/bd
T. Nicrdia -retard 20mg/po/bd
T.nodosin 500mg po/Tid
T.oeofer-×7/po/bd
T.shelcal 500mg/po/od
Inj.erythropoetin 400Iu sc weekly once.
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