A 60 year old male patient of CKD came for regular dialysis.
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A 60 year old male patient of resident nalgonda came to opd 4 days back for regular dialysis.
HOPI
1)The patient was apparently asymptomatic 3 years ago then he developed bilateral pitting type of pedal edema .
2)The patient also developed shortness of breath grade 4 which is insidious in onset and gradually progressive associated with orthopnea 2 years back aggrevated on exertion and releived on sitting.
The patient also had decreased urine output.
No complaints of chest pain,palpitations.
Past history
He is a known case if diabetes and hypertension since 30 years ,he is on medication( HAI ,Nicardia.)
No history of asthma, CAD,epilepsy,tuberculosis.
Personal history
Diet - Mixed
Bowels and bladder-Regular
Sleep -Adequate
Appetite- Normal.
Addictions- Occasionally alcoholic
He has habit of chewing gutka since 15 years but he stopped 5 years back.
Family history - Not significant
General examination
Patient is conscious ,coherent, co operative well oriented to day, time,place, and person.
He is well built and well nourished.
Pallor -present
No icterus, cyanosis,clubbing ,lymphadenopathy.
Vitals
Temp-Afebrile
BP -140/70 mm hg
RR-18cpm
PR-90bpm
Systemic examination
CVS -S1,S2 heard.No murmurs
RS- Bilateral vesicular breath sounds are heard
P/A - soft non tender, Bowel sounds heard.
CNS- No focal neurological deficits.
Investigations
Provisional diagnosis - CKD on maintenance hemodialysis
The patient has undergone 14 sessions of dialysis first session started on 17 January and he is advised for dialysis twice a week.
Treatment
Tab-LASIX40 Mg BD
Tab -SHELCAL PO OD
TAB- NODOSIS 500 mg BD
TAB- ECOSPRIN 75/10 mg OD
TAB-CLINIDIPINE-10 Mg OD
TAB-Injection - HAI subcutaneously
Fluid and salt restriction
Syrup -ASCORIL 10 ml TID
Nebulizer- MUCOMIX 6 Hrly
IPRAVENT 8 Hrly
BUDECORT 12 hrly
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