FINALS SHORT CASE
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Date of Admission- 05 -02-22
A 25 year old Male presented to OPD with chief complaints of vomitings 10 episodes and bipedal edema and decreased Urinary output since 3 years .
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years ago then he developed multiple episodes of vomitings for which he was admitted in the hospital and found to have high BP of 170 mm Hg .
HISTORY OF PAST ILLNESS
Known history of hypertension .
Known history of Tuberculosis
No history of Diabetes mellitus asthma, epilepsy.
No history of surgeries, chemotherapy or radiotherapy
PERSONAL HISTORY
Diet - Mixed
Appetite- Normal
Bowel movement is regular .
Micturition - Normal
Addictions- None
Sleep - Regular
FAMILY HISTORY
No history of DM, CAD, Asthma and thyroid disorders in the family
GENRAL EXAMINATION
Patient is conscious, coherent, co-operative.
There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy
VITALS
Temperature- 98.4 ⁰F
Pulse rate- 78 bpm
Respiratory rate - 13cpm
BP- 130/80 mm Hg
Spo2- 98%
GRBS -112mg/dl
SYSTEMIC EXAMINATION:
Cardiovascular System
Cardiac sounds- S1, S2 are heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea- central
Breath sounds- vesicular
Adventitious sounds- No
ABDOMEN
Shape of abdomen - Scaphoid
No tenderness .
Hernial orifices -Normal
Palpable mass- None
Free fluid- none
Liver- Not palpable
Spleen- Not palpable
Bowel sound- Heard.
CENTRAL NERVOUS SYSTEM
Patient is conscious
Speech- normal
No sign of meningitis
Motor and sensory system- Normal
Neck stiffness - none
Kernings sign - none
Cranial nerves- intact
Investigation
Hemogram : Hb - 7.5 gm/dl
Total cell count -9700 cells / cubic mm
Neutrophils-71 %
MCV -91.7
MCHC - 33.8
Serum electrolyte
Creatinine - 5.4
Na + 146 mEq/L
K+ 3.9 mEq/L
Cl 98 mEq/
Provisional diagnosis- chronic kidney disease
TREATMENT
Conservative- Maintaince Heamodialysis
On 05 -02-22
Fluid restriction < 1L / day
Salt restriction < 2.4 g / day
Tab. Nicardia 10 mg BD
Tab . Lasix 40 mg BD
Tab . Shelac OD
Tab . Pan 40 mg OD
Tab . Ororex XT OD
Tab . Nodosis. 550 mg OD
On 9-2-22
Tab. Nicardia 10 mg BD
Tab . Lasix 40 mg BD
Tab . Shelac OD
Tab . Pan 40 mg OD
Tab . Ororex XT OD
Tab . Nodosis. 550 mg OD
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