Case study 1

 

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This is a case of 45 year male patient who is a farmer by occupation presented with chief compliant of swelling of lower limbs, difficulty in breathing since 1 and 1/2  year and decreased urine output. 

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 3 mnths back. 

Then he was diagnosed covid positive

Later he developed Pedal edema which was gradual in onset and progressive in nature, pitting type. 

He had shortness of breath, decreased urine output, orthopnea and dyspnea. 

No vomitings. 

Presently he is on dialysis.(thrice weekly, alternate days for 4 times) 

Symptoms subsided on dialysis. 

PAST MEDICAL HISTORY:-

known case of hypertension since 1 and half year

No asthma, no epilepsy, no TB, no diabetis

PERSONAL HISTORY:

Diet -was mixed till 3 months back, 

Appetite : normal

Bowel & Bladder movements: regular

Sleep :adequate

Addictions: Alcoholic but stopped 4months back, no smoking. 

FAMILY HISTORY:-

no history of  similar complaints in the family.

TREATMENT HISTORY:-

no history of drug allergies.

GENERAL EXAMINATION:-

 patient was conscious,coherent and cooperative

 he has pedal edema which extended from feet to knee which is subsided after dialysis

He has pallor

no clubbing

No cyanosis, 

No icterus, 

No generalised lymphadenopathy

VITALS-

temperature - 37degree Celsius

Pulse - 82 bpm

Respiratory rate - 22 cpm

Bp-140/90

SYSTEMIC EXAMINATION -

CVS-inspection

Chest wall is bilaterally symmetrical.

No precardial bulge

No visible pulsations, engorged veins, scars and sinuses

PALPATION

Jvp is normal

AUSCULTATION -

S1 ans s2 heard

RESPIRATORY SYSTEM:

Bilateral air entry is normal.(BAE) 

Dyspnea is present.

Normal vesicular breath sounds heard( NVBS).

PER ABDOMEN:-

abdomen is not tender and soft

CNS:-

patient is concious

Speech is present and normal.

PROVISIONAL DIAGNOSIS:- kidney disease

Investigations:-

29/07/2021

SERUM CREATININE

*Serum creatinine-#6. 2 mg/dl(0.9-1.3) 

TOTAL PROTEINS A/G RATIO serum

*serum protein  #4.6g/dl (6.4 -8. 3) 

* albumin #3.0 g/dl(3.5 -5. 2) 

*A/G ratio 1.87

BLOOD UREA

*Blood urea :-#145 mg/dl(12- 45) 

SERUM ELECTROLYTES:-

Sodium #135 mEq/l(136-145) 

Potassium 5.1mEq/l(3.5-5.1) 

Chloride 102mEq/l(98-107) 

Complete urine examination 29/07/2

7/08/21

Hemogram 29/07/21

FINAL DIAGNOSIS:- CHRONIC RENAL FAILURE
(also ANEMIA) 

TREATMENT:-

TREATMENT:

T. Lasix 40 mg-morning and night

T. Cilacar 10 mg-morning

T. Cilacar 20 mg night

T. Nodosis 500mg-evening

T.orofer xt -morning and night

Injection Erythropoietin 4000IU

SC weekly twice

Fluid retention <1.5 L/day

Salt restriction <4mg/day