General medicine case 

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A 65 old male who is builder by occupation hailing from bhuvanagiri presented our causality with cheif complaint of shortness of breath and pedal edema since 20days and gradual weight loss 

Date of admission :-05/12/2021

History of present illness:-

Daily routine of the patient:-

Patient wakes up a 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 2pints 
He completed dialysis of 12cycles 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 pains 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/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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