GM CASE 6

 K.meghana 39 , k.Sai likhitha 37

 Date of admission:18/09/2021

 39 years old male who doesn't have any proper occupation came with the chief complaints of abdominal discomfort and SOB since 3days.

  History of present illness:

  Patient has similar complaints since 5 years .

Before diagonosing he had fever and loss of appetite since 1mon and also with cough, cold and throat infection along with back pain  and he visited local hospital where they identified is creatinine high and let to kidney failure.

Before 3years he visited our hospital and he is undergoing dialysis since 3years weekly once.

Past history:

He had no similar complaints in the past. 

He has hypertension since 2years 

 No h/o diabetes 

No h/o epilepsy

No h/o TB

No h/o asthma 

No history of any previous surgery in the past. 

Person history:

 Appetite:normal 

Diet:mixed 

Adequate:sleep 

Bowel and bladder movements :normal 

 Occasionally alcohol since 20 years. Cigarette 2 per day.

Family history:

No similar complaints in the family. 

Drug history:

No allergy to known drugs. 

General examination:

 Patient is conscious,coherent, cooperative. 

Pallor is present 

No cyanosis 

No lymphadenopathy 

No clubbing 

No icterus 

No edema

No tremors 

Vitals:

Temp:afebrile

Pulse rate:82/min

RR:18/min

 Bp:130/90

Systemic examination:- 

 Cvs:

S1 and s2 are heard .

 Respiratory system 

No dysponea 

Position of trachea central .

Abdomen:

Shape distended and obese 

Non tender 

CNS

   Patient is conscious 

Speech is normal 



Investigations:
Ultrasound:
Blood sugar:


Serum iron:

Hemogram:


ECG:


Final diagnosis:
   Ckd on mhd
 Treatment plan:

Tab lasix -40mg Po/Bd
Tab nicardia-20mg po/bd
Tab Nodasis-500mg po/bd
Tab Orofer XT po/bd 
Tab shelcal-500mg po/bd
Tab pan-40mg po/bd
Bp Pr rr monitoring

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