GM Case presentation
Date of admission:2/8/21
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A 45 years old man presented to the OPD with cheif complaints of Swelling of both the legs and Shortness of breath from past 2 months.
HISTORY OF PRESENT ILLNESSES
Patient was apparently asymptomatic 4months back
Then he complained of Bilateral Pedal Edema which was gradually progressive,pitting type,below the knee.
He also complained Shortness of breath(Grade2)and pain in the legs. Then they went to nearest medical care and daignosed with kidney problem and was started on medication
6 days back patient presented to the casuality with swelling in the legs and shortness of breath for which he adviced to undergo dialysis
3 dialysis units have been done till 10/8/21
HISTORY OF PAST ILLNESSES
Patient is a known case of HTN from past 1 year
Not a known case of DM,TTS,Asthama and Epilepsy
No history of surgeries and blood transfusions in the past
FAMILY HISTORY
Patient's father was known case of B.P
Patient's mother was a known case of Sugar and B.P
No history of CVA,CAD, Asthama and Thyroid disorder in the family
GENERAL EXAMINATION
Patient is conscious, coherent, cooperative
There is Pedal Edema
No pallor,clubbing,koilonychia and lymphadenopathy
VITALS
Temperature: 37.5°C
Pulse rate: 80/min
Respiratory rate: 16breath/min
BP : 110/80 mmHg
SYSTEMIC EXAMINATION
CARDIOVASCULAR CYST
Chest wall is bilaterally symmetric
No precordial bulg
No visible pulsations, engorged veins,scars and sinue
PALPATION
Apex beat : felt in the left 5th intercostal space in mid clavicular lin
AUSCULTATION
S1 and S2 heared
RESPIRATORY CYST
Position of trachea - centre
Bilateral air entry :+
Normal vesicular breath sounds - heared
PER ABDOMINAL
Abdomen distended,soft and non tender
Bowel sounds heared
No palpable mass or free fluid
CENTRAL NERVOUS SYST
Patient is conscious, coherent,coperative with normal speech
and
No signs of meningeal irritation
Sensory and motor reflexes: intact
PROVISIONAL DIAGNOSIS
Chronic renal failure
INVESTIGATION
LFT
Total bilirubin: 0.81 mg/dl
Direct bilirubin: 0.20 mg/dl
SGOT: 12 IU/L
SGPT: 10 IU/L
Alkaline phosphatase: #283 IU/L
Total proteins: # 6.3 gm/dl
Albumin: 3.6 gm/dl
Phosphorus: #6.0 mg/dl
Calcium: 9.4 mg/dl
Serum iron 72 micro g/dl
RBS : 109 mg/dl
Blood urea : # 97 mg/dl
Serum creatinine : # 7.5 mg/dl
SERUM ELECTROLYTE
Sodium: 137 mEq/L
Potassium: 4.4 mEq/L
Chloride : 99 mEq/L
CBP
 |
ECG
CUE
CLINICAL DIAGNOSIS
REPORT
TREATMENT
Since patient has Hb 6.6 gm/dl he undervent blood transfusion (PRBC) on 08/08/21
1. Tab. NICARDIA R 6 TARD 20mg PO/BD
2. Tab. NODOSIS 500mg PO/OD
3. Tab. OROFER XT PO/BD
4. Tab. SHELAC AC CT PO/BD
5. Inj. ERYTHROPOIETIN 4000 IO.
S/C weekly twice
6. Inj. IRON SUCROSE 10mp in 50ml
NS/IV/ Weekly once.
7. Fluid restriction < 1.5 L/day.
8. Salt restriction < 4 gm/day
9. T. LASIX 40 mg PO/BD
POSSIBLE QUESTIONS TO ASK
1,Sir, the most commonest cause for CKD is Diabates but my patient is not a diabatic?
2,other causes would be
Usage of NSAIDS,
renal calculi and
Hypertension
3,what is the exact cause of CKD?
4,as my patient is only hypertension,can I conclude the only hypertension is the cause?
5,Will kidney Biopsy helps here?
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