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