CKD WARD CASE

MEDICAL CASE DISCUSSION 

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A 60 yr old male resident of nakrekal, his daily routine was mud digging since 30 years. He stopped working since 6 months as his family doesn't want him to work. 

Patient complains of decreased urine output since 2 months

Patient was apparently asymptomatic 2 months back then he had decreased urine output associated with burning micturition . For this reason he went to Hyderabad hospital there he was diagnosed with kidney problem (Sr.Creatinine- 8 mg/dl) and then started with dialysis .

There he had undergo 6 dialysis ( 2 per week) and then discharged

Now he came to our hospital for dialysis(4 completed).

PAST HISTORY:

Not a Known case of HTN, DM, TB, ASTHMA, CAD,CVD

PERSONAL HISTORY:

Mixed-diet

Sleep- normal

Appetite -normal

Bowel movements- regular

Decreased urine output

Chronic alcoholic since 40 years,drinks daily at night 

FAMILY HISTORY 

No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.

GENERAL EXAMINATION:

Patient is conscious, coherent, co-operative.

Moderately built and moderately nourished

No pallor, cyanosis, clubbing,icterus koilonychia, lymphadenopathy and edema

VITALS 

Temperature- 104F

Pulse rate- 96 bpm

Respiratory Rate- 16 cpm

BP-110/80 mmHg 

SPO2 at room air- 98%

GRBS 104 mg/dl

SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM:

S1, S2 heard , No murmurs

RESPIRATORY SYSTEM-

Position of trachea: central

Bilateral air entry +

Normal vesicular breath sounds - heard

No added sounds.

PER ABDOMEN:

Abdomen is soft and non tender.

No organomegaly.

Bowel sounds heard.

No palpable mass or free fluid 

CENTRAL NERVOUS SYSTEM:

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: present

Cranial nerves: intact

INVESTIGATIONS-

Hb- 9.9gm/dldl

Blood group and typing - O positive

RBS -144 mg/dl

Blood Urea- 99 mg/dl

Serum Creatinine- 5.7mg/dl

Serum Na - 141 mEq/L

Serum K- 3.3 mEq/L

Serum Cl- 98 mEq/L

Serum amylase- 93.9IU/L

LFT-

CUE

CHEST X RAY

USG

Serology- Negative

PROVISIONAL DIAGNOSIS - CKD ON MHD

TREATMENT-

TAB.NICARDIA 20 MG /PO/BD

TAB.NODOSIS 500MG/PO/BD

TAB.SHELCAL PO/OD

TAB.OROFER PO/OD

INJ.ERYTHROPOIETIN 4000 IU SUBCUTANEOUS WEEKLY ONCE

FLUID RESTRICTION

SALT RESTRICTION