74 year old male



DOA-7/6/24
DOD-17/06/25
CKD duration-not known

DIAGNOSIS -

CKD STAGE 5 INITIATED MHO K/C/O DIABETES TYPE 2 SINCE 15 YEARS K/C/O HYPERTENSION SINCE 5 YEARS WITH UREMIC PRURITIS

Case History and Clinical Findings
PATIENT CAME WITH C/O BILATERAL PEDAL EDEMA SINCE 1 MONTH ,GENERALISED WEAKNESS,ABDOMINAL DISCOMFORT HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO , HE DEVELOPED BILATERAL PEDAL EDEMA PITTING TYPE, EXTENDING UPTO THE KNEE,GENERALISED WEAKNESS PRESENT,LOSS OF APPETITE PRESENT ,ITCHING ALL OVER THE BODY ,ABDOMINAL DISCOMFORT PRESENT MORE AFTER EATING FOOD

 PAST HISTORY:
K/C/O HYPERTENSION SINCE 5 YEARS ON TAB CINOD 10 +METAPROLOL 25MG K/C/O TYPE 2 DIABETES SINCE 15 YEARS ON TAB TELMAGLIPTIN K/C/O CKD
N/K/C/O DM,TB, ASTHMA THYROID, EPILEPSY
 GENERAL EXAMINATION :
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE NO PALLOR, ICTERUS, CYANOSIS, CLUBBING
AT ADMISSION
TEMP:98.5'F
PR:84BPM
RR:18 CPM
BP:110/70mmHg
SPO2:98@RA 2L 02
SYSTEMIC EXAMINATION
CVS:S1 S2+ , NO MURMURS
RS:BAE+, NVBS+
PA: SOFT,NONTENDER
NO ORGANOMEGALY
CNS : PATIENT IS CONSCIOUS, COHERENT AND CO-OPERATIVE AND WELL ORIENTED TO
TIME, PLACE AND PERSON
HIGHER MENTAL FUNCTIONS INTACT. NO FOCAL NEUROLOGICAL DEFICITS
REFLEXES : RIGHT LEFT
BICEPS +2 +2
TRICEPS +2 +2
SUPINATOR +2 +2
KNEE +2 +2
ANKLE +2 +2


COURSE IN THE HOSPITAL:
THE ABOVE MENTIONED COMPLAINTS PATIENT WAS EVALUATED CLINICALLY AND WITH
APPROPRIATE INVESTIGATIONS I/V/O DERANGED RFTS CENTRAL LINE CATHETERISATION
WAS DONE AND 4 SESSIONS OF HEAMODIALYSIS WAS DONE DURING THE HOSPITAL STAY
. PATIENT WAS HEAMODYNAMICALLY STABLE AND DISCHARGE IN STABLE CONDITION .

Investigation

Hb-10.3
MCV -82.4
MCH -26.9
MCHC -31.4
TLC -7600
Plt-2.8

S.iron-79
S.ferritin-321

Smear - NORMOCYTIC NORMOCHROMIC 


(LFT) 
Total Bilurubin 0.59 mg/dl
Direct Bilurubin0.18 mg/dl
SGOT(AST)14 IU/L
SGPT(ALT)10 IU/L
ALKALINE PHOSPHATASE199 IU/L
TOTAL PROTEINS6.2 gm/dl
ALBUMIN3.16 gm/dl
A/G RATIO1.04

SERUM CREATININE -6.1 mg/dl
BLOOD UREA-58 mg/dl
URIC ACID
5.0 mmol/L
CALCIUM
10.0 mg/dl
PHOSPHOROUS
4.0 mg/dl
SODIUM
141 mmol/L
POTASSIUM
4.8 mmol/L.
CHLORIDE106 mmol/L

2d echo -
Ef-53%
Grade 1 diastolic dysfunction 
LVH+

INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/2WEEKS
PRBC TRANSFUSED -0
ADMISSION IN ICU -0

Treatment Given(Enter only Generic Name) 1)FLUID RESTRICTION <1.5 L/DAY 
2)SALT RESTRICTION <2 G/DAY
 3)INJ EPO 4000IU/ SC/ WEEKLY ONCE
4)TAB CLINIDIPINE10MG+TABMETOPROLOL 20MG PO/BD 
5)TAB TENLIGLIPTIN 20MG PO/BD
 6)TAB NODOSIS 500MG PO/BD
 7)TAB SHELCAL CT PO/BD 
8)TAB NICARDIA 20MG PO/BD
9)LIQUID PARAFFIN FOR L/A FOR 2 WEEKSS 10) TAB OROFER XT PO/OD 
11)ATARAX LOTION L/A SOS

 Advice at Discharge
1)TAB CLINIDIPINE10MG+TABMETOPROLOL 20MG PO/BD X5DAYS
 2)TAB TENLIGLIPTIN 20MG PO/BD X5DAYS 3)TAB NODOSIS 500MG PO/BD X5DAYS
 4)TAB SHELCAL CT PO/BDX5DAYS
 5)TAB NICARDIA 20MG PO/BD X5DAYS
 6)TAB ECOSPIRIN AV (75/10) PO/HS X5DAYS 
7) TAB OROFER XT PO/ODX5DAYS

FOLLOW UP AT 3MONTHS 
HB-9.7
MCV-79.3
MCH-29.8
MCHC -30.3
TLC -8709
PLT-2.14

FOLLOW UP AT THE END OF THESIS 
LOST TO FOLLOW UP .

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