Case of Chronic Kidney Disease

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Date of admission : 04/08/2021

A 55 year old man,mechanic by occupation presented to the OPD with chief complaints of decreased urine output since 1 day.


HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic from past one year.On date 20/7/2021 patient had sudden onset of shortness of breath so taken to hospital,treated with oxygen supply. Doctors told him that he has elevated creatinine levels in blood and advised to undergo dialysis.

On 26/7/21 patient is being prepared for  central venous pressure (CVP) line,he suffered from cardiac arrest and resuscitated.

He had 6 cycles of dialysis from 28/7/21 to 02/8/21. After his 6th dialysis discharged from hospital.Then he developed decreased urine output for which he was brought to us .He is still suffering with SOB ,treating with oxygen supply and undergoing dialysis.


HISTORY OF PAST ILLNESS :

Patient was alright till 1997 when he had fall from a current pole after which he had injury to left upper limb,left lower limb and lower back for which he started using painkillers daily till one month back.

6 years back he started developing bilateral pedal edema in lower limb - pitting type extending upto both knees.

6years back he also developed bilateral knee joint pain and swelling .

Patient gives history of trauma one month back to right lower limb at ankle due to bike accident and was prescribed some antibiotics .Wound didn't subsided with antibiotics. 

Patient is not known case of diabetes mellitus, hypertension,coronary artery disease, asthma, tuberculosis and any surgeries.


PERSONAL HISTORY :

Diet - Mixed

Appetite - Normal 

Sleep - inadequate 

Bladder movements - decreased urine output 

Bowel movements are regular

Addictions - history of alcohol intake since 25 years 


FAMILY HISTORY  : 

No history of similar complaints in the family .


GENERAL EXAMINATION : 

Patient is conscious, coherent and cooperative.

There is no icterus. 

Pitting type of oedema is seen extending upto knees.

No pallor,no cyanosis.

Clubbing of toes is seen.

No lymphadenopathy , no malnutrition.

 
VITALS : 

Temperature - 98°F

Pulse rate  - 87bpm

Respiratory rate - 22cpm 

BP - 120/70mm/Hg 

SPO2 at room air 98% on 4L of O2 

General Random Blood Sugar - 154mg % 


SYSTEMIC EXAMINATION : 

Cardiovascular system :

No Thrills 
S1 and S2 sounds heard 
No signs of Cardiac murmurs 

Respiratory system :

Position of trachea - central 
Dysponea is seen 
No sign of wheeze 
Inspiratory crepts in left sacroanterior and left atrial appendage 

Abdomen : 

Shape of abdomen - obese 
Tenderness not seen
No palpable mass
Hermial orifices - Normal 
No free fluid 
No briuts 
Liver is not palpable
Spleen is not palpable 
Bowel sounds heard 

Central nervous system : 

Patient is conscious 
Speech - normal
No signs of meningeal irritation
Motor and sensory system - normal 
Cranial nerves - normal 


INVESTIGATIONS : 

Plasma - fasting blood sugar level 
Plasma post prandial blood sugar level
Serum creatinine 
Serum potassium 
Serum phosphorus  
Hemogram : 




ECG :




TREATMENT: 

Fluild restrictions < 2lit per day 
Salt restrictions < 2gm per day 
Inj.piptaz - 2.25gm / IV / TID 
Tab . Flucanazole -100mg / OD
Protein powder 2 tablespoon in 100ml of milk /BD

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