CASE 39

59 year old male
DOA -19/2/2024
DOD -5/3/2024
CKD DURATION- 4years and is on maintenance hemodialysis since 2years.

DIAGNOSIS 
CHRONIC KIDNEY DISEASE ON MAINTENANCE AND HEMODIALYSIS 
HYPERTENSION 
DIABETES MELLITUS TYPE 2 

Case History and Clinical Findings
 C/O SOB SINCE 2DAYS
C/O DECREASED URINE OUTPUT SINCE 2DAYS

HOPI:
PT WAS APPARENTLY ASYMPTOMATIC TILL 18 AND HALF YEARS AGO THEN HE DEVELOPED SOB[GRADE III] WITH B/L PEDAL EDEMA FOR WHICH HE WAS INITIATED ON HEMODIALYSIS.PT WAS DIAGNOSED AS CKD 4YRS AGO AND WAS ON CONSERVATIVE MANAGEMENT SINCE THEN,LAST DIALYSIS WAS ON 17/2/24 OUTSIDE HOSPITAL. NO H/O FEVER,CHEST PAIN,PALPITATIONS,VOMITINGS,COUGH,COLD AND BURNING MICTURITION


PAST HISTORY:
K/C/O DM II SINCE10YRS (ON INJ HAI S/C BD 10U--X--4U) K/C/O HTN SINCE5YRS (ON TAB NICARDIA 10MG PO/TID) .
K/C/O CKD SINCE 4YRS (ON MHD SINCE 18MONTHS) 
NOT A K/C/O CAD,CVA,EPILEPSY,TB,ASTHMA AND THYROID DISORDERS .

PERSONAL HISTORY: 
APPETITE-NORMAL SLEEP-ADEQUATE
BOWEL MOVEMENTS-REGULAR
 DECREASED URINE OUTPUT

GENERAL EXAMINATION
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY AND PEDAL EDEMA
TEMP-97.6 F
RR 20 CPM
BP-140/80 MM HG
SPO2 96% @RA
CVS - S1S2 HEARD,NO MURMURS
RS - BAE PRESENT
P/A - SOFT ,NON TENDER NO ORGANOMEGALY
CNS - NFND

Investigation
HB-10.4
MCV -85.6
MCH -26.8
MCHC -28.5
TLC -4500
PLT -1.98

S.iron -45
S.ferritin-169.6

SMEAR -NORMOCYTIC NORMOCHROMIC 

RBS-214 MG/DL

RFT
UR-196 mg/dl
CR-6.9 mg/dl
NA+--136 Eq/L
K+-5.1 mEq/L
CL-99 mEq/L


HIV-NEGATIVE
HBSAG-NEGATIVE
HCV-NEGATIVE

USG ABDOMEN AND PELVIS:
IMPRESSION-BILATERAL GRADE II RPD CHANGES.

2D ECHO -
EF -66% GRADE 1 DIASTOLIC DYSFUNCTION 
CONCENTRIC LVH 

Treatment Given(Enter only Generic Name)
FLUID RESTRICTION LESS THAN 1.5 L/DAY
SALT RESTRICTION LESS THAN 2-3 GM/DAY
INJ EPO 4000 IU ONCE A WEEK
INJ.IRON SUCROSE 1AMP IN 100ML NS IV OD
ALTERNATE DAY
T OROFER XT PO/OD
T SHELCAL CT PO/OD
T PAN 40MG PO/OD

Advice at Discharge
FLUID RESTRICTION LESS THAN 1.5 L/DAY
SALT RESTRICTION LESS THAN 2-3 GM/DAY INJ EPO 4000 IU ONCE A WEEK 
T OROFER XT PO/OD X 2 WEEKS
 T SHELCAL CT PO/OD X 2 WEEKS
 T PAN 40MG PO/OD X 1WEEK
INJ.IRON SUCROSE 1AMP IN 100ML NS IV OD
ALTERNATE DAY


follow up at 3months 
HB -10.6
MCV -85.3
MCH -28.7
MCHC -29.8
TLC -6700
PLT -2.7

Follow up at the end of thesis 
-patient has expired due to myocardial infarction.

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