52/M with CKD with HTN
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A 52 yr old gentleman who is a father to two children and shopkeeper by occupation came to our hospital on 18/02/2022.
USG REPORT
H/O PRESENT ILLNESS :
Patient was apparently asymptomatic 1 year ago,then he developed loss of appetite, decreased urine output and loin pain for which he went to local hospital where he was diagnosed to have renal calculi.Patient did not take any medical treatment for renal calculi instead he chose to take ayurvedic medication after which he developed severe vomitings and diarrhoea and generalised weakness.Then he got admitted in a hospital in Hyderabad where he was diagnosed to have CKD for which he received 10 sessions of hemodialysis.
In November 2021, Patient came to our hospital for the first time for receiving hemodialysis as he couldn't afford hemodialysis in Hyderabad.He received 10 hemodialysis sessions here in our hospital.
Now , again he came to our hospital for another session of hemodialysis.
PAST HISTORY :
Patient is Hypertensive since 1 year and is on medication.
PERSONAL HISTORY :
Diet : Mixed
Appetite : Normal
Bowel and bladder movements : Regular
Sleep : Adequate
Addictions : Gutka chewer since 20 years
GENERAL EXAMINATION :
O/E
Patient is conscious,coherent and cooperative.Moderately built and nourished.
Pallor +
No icterus, clubbing, koilonychia, lymphadenopathy, pedal edema
VITALS :
Temp : afebrile
BP : 130/80 mm Hg
PR : 76 bpm
RR : 16 cpm
CVS : S1S2+, No murmurs
RS : BAE +, NVBS +
P/A : Soft,Non tender
CNS : NAD
INVESTIGATIONS :
Hb : 8.8 gm/dl
TLC : 5600 cells / cu.mm
PLT : 2.36 lakhs / cu.mm
Urea - 93 mg/dl
Creatinine - 7.3 mg/dl
Serum Iron - 76 ug/dl
TREATMENT :
1. FLUID RESTRICTION < 1L/DAY
2. SALT RESTRICTION < 2 GM/DAY
3.TAB LASIX 40MG PO/BD
4.TAB SHELCAL CT PO/OD
5. TAB OROFER XT PO /OD
