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A 39 year old male patient is on maintenance haemodialysis since 2 years.
HOPI:
Patient was apparently asymtomatic 2 years back and then developed shortness of breath (on and off), pedal oedema (pitting type), pain abdomen, squeezing type, headache and dizziness. Later diagnosed as chronic renal failure and underwent dialysis twice weekly Last year a few times he underwent dialysis thrice weekly. Presently he is undergoing dialysis twice weekly.
PAST HISTORY:
k/c/o HTN since 3 years.
Not a K/C/O of DM, thyroid disorders, TB
PERSONAL HISTORY:
He follows a mixed diet. Appetite -Normal, Bladder movements-normal
Bowel movements-normal since few weeks. Sleep- decreased.
consumes alcohol occasionally and stopped 2 years back.
FAMILY HISTORY:
No significant family history
.
DRUG HISTORY:
No known drug allegies and patient uses amlodipine 5mg,arkamin clonidine 100mcg,metxl 25mg.
GENERAL EXAMINATION:
Patient is conscious ,coherent, co operative and well oriented to his surroundings.
He is poorly built and nourished.
No pallor ,no cyanosis, no icterus, no lymphadenopathy.
B/l pedal edema has decreased .
VITALS:.
Temperature: afebrile.
Pulse rate: 88 beats / min.
Respiratory rate: 21cycles / min.
Bp: 150/100.
Spo2: 99
GRBS-130Mg/dl.
SYSTEMIC EXAMINATION:
Cvs: S1& S2 heard.
RESPIRATORY SYSTEM : BAE +, Position of trachea- central, no adventious sounds heard
CNS: patient is normal and concious .reflexs are normal.
Clinical findings:
Investigations.
BGT : B POSITIVE
Sr IRON: 71 ug/dl
Sr creatinine: 9.3 mg/dl
Blood urea: 71 mg/dl
USG :
PROVISIONAL DIAGNOSIS: Chronic renal failure
TREATMENT:
1. Fluid restriction (<1l/day)
2. Salt restriction (<2g/day)
3. T· LASIX 40 mg PO BD
4. T. Nicardia 10mg PO BD
5. T. NODOSIS 500 MG PO BD
6. T. OROFER-XT PO BD
7. T. Shelcall XT 1TAB PO OD
8. Inj.ERYTHROMYCIN 4000IU /sc weekly once
9. Inj. IRON SUCROSE 100 MG IN 100 ML NS DURING DIALYSIS
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