General Medicine case 3

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Date of admission:29/12/2021

A 45 year old who is mechanic by occupation present to opd with chief complaint of SOB , loss of appetite since 20 days and low backache since 5 days.

History of present illness:

 Patient was apparently asymptomatic 35days back, then he developed shortness of breath for which he went to a local hospital after further investigation he was diagnosed with chronic kidney disease and underwent 4 sessions of dialysis.Then referred I/V/O dialysis.

He was diagnosed with hypertension 1 month back and is on regular medication( Tab. Nicardia 10mg od) since then.

 

Past history:

Not a known case of DM, Thyroid, TB, asthama, epilepsy.

K/c/o: kidney failure 

Personal history:

Apetite decreased since 20 days.

He takes mixed diet.

Bowel and bladder movements are regular.

No any known allergies.

Patient consumes alcohol 1 quarter of whisky/ day daily since 12 years.Last consumption was 20 days back.

He is a known smoker.2 packs of cigarettes/ day since 20 years.

General examination:

Pallor present

No icterus, cyanosis , clubbing , lymphadenopathy.

Edema present

Vitals:

PR : 88bpm

RR : 18 cpm

BP : 140/90 mmhg

Spo2 : 99% at RA

GRBS : 153 mg%

Provisional diagnosis :

CKD on MHD since 1 month.

Treatment:

Tab.Nicardia 20mg po/bd

Tab.Nodosis 550 mg po/od

Tab.Orofer XT po/od

Tab.Shelcal 500mg po/od

Clinical Images: