Case history - 5
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A 65 year old male patient came to the casuality with chief complaint of fever, generalized weakness, decreased urine output ,burning micturition ,bipedal edema.
History of present illness :
Patient was apparently asymptomatic 2 months back then he developed generalized weakness, burning micturition , decreased urine output, fever, bipedal edema.
Patient was diagnosed with renal acute kidney infection secondary to urinary tract infection.
Patient was advised to take dialysis and his first dialysis was initiated on 12 August 2021.
Patient was again readmitted as Chronic kidney disease on maintenance hemodialysis on 30 August .
About 15 sessions of hemodialysis are done .
Patient was again readmitted for dialysis.
Past history :
Patient is known case of hypertension.
No history of diabetes, CAD,asthma , Tuberculosis .
No history of surgeries.
Personal history :
Appetite - normal
Diet - mixed
Bowel and bladder movements - regular
Addictions - regular alcoholic
Non smoker
Family history :
No other members of the family have similar complaints.
General examination
Patient is conscious, coherent,non cooperative and moderately built & nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Edema - bipedal edema
VITALS :
Temperature - Afebrile
Respiratory rate - 24/ min
Pulse rate - 84/ min
Blood pressure - 130 /70 mmHg
SpO2 - 92 %
SYSTEMIC EXAMINATION
CVS :
No thrills
S1,S2 heard
No cardiac murmurs
Respiratory rate :
No dyspnea
No wheeze
Breath sounds - vesicular
Abdomen :
Shape of abdomen - scaphoid
No Tenderness
No palpable mass
No free fluid
No bruits
CNS:
Level of consciousness - conscious
Speech - normal
No neck stiffness
INVESTIGATIONS :
Provisional diagnosis :
Chronic kidney disease on maintenance hemodialysis .
Treatment :
Inj Pan
Inj Piptaz
Tab nicardia
Tab Lasix
Tab Shelcal
Tab Nodosis
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