case 5

Case 6 -
43 year old male
DOA -29/8/24
DOD-29/09/24
CKD duration-2 months 

DIAGNOSIS -
CKD ON MHD
K/C/O HTN SINCE 2YRS

 CHIEF COMPLAINTS
C/O SOB SINCE 4 DAYS 


HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO THEN NOTICED SOB, INSIDIOUS IN ONSET AND GRADUALLY POROGRESSIVE FROM GRADE-1 TO GRADE-2 NO AGGRAVATING AND RELIEVING FACTORS.
C/O PEDAL EDEMA SINCE 2 MONTHS, PITTING TYP EXTENDING UPTO ANKLE NO C/O DECREASED URINE OUTPUT NO C/O CHEST PAIN, PALPITATIONS, H/O FEVER 1 WEEK BACK

PAST HISTORY
K/C/O HTN SINCE 2 YRS AND OIS ON MEDICATION N/K/C/O DM , ASTMA, TB, EPILEPSY, CVA, CAD, THYROID DISORDERS

GENERAL EXAMINATION
 PT IS C/C/C
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, PEDAL EDEMA, LYMPHADENOAPTHY


BP- 130/80 MM HG 
PR- 82BPM
RR- 20CPM
TEMP- 92.8F
GRBS- 102 MG%


SYSTEMIC EXAMINATION
CVS- S1,S2+, NO MURMURS
RS- BAE+
CNS-NFND
PER ABDOMEN - SOFT, NT

Investigation

HB-10.1
MCV-87.6
MCH-35.7
MCHC-35.7
TLC-9700
PLT-1.8

PERIPHERAL SMEAR -NORMOCYTIC NORMOCHROMIC 

S IRON-89
S.FERRITIN-276.7

RFT 
UREA 240 mg/dl
CREATININE 10.0 mg/dl
URIC ACID 8.5mmol/L
CALCIUM 7.9 mg/dl
PHOSPHOROUS 4.4 mg/dl
SODIUM 145 mmol/L
POTASSIUM 4.8mmol/L
CHLORIDE 102 mmol/L

LFT 
Total Bilurubin 0.94 mg/dl
Direct Bilurubin 0.19 mg/dl
SGOT(AST) 13 IU/L
SGPT(ALT) 15 IU/L
ALKALINE PHOSPHATASE 121 IU/L
TOTAL PROTEINS 5.6 gm/dl
ALBUMIN 3.28 gm/dl
A/G RATIO 1.41

2D ECHO -
EF -60% 
NO DIASTOLIC DYSFUNCTION 

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)
FLUID RESTRICTION <1.5 LIT/DAY
SALT RESTRICTION <2GM/DAY
INJ. EPO 4000IU SC ONCE WEEKLY
INJ. IRON SUCROSE 100MG IN 100ML NS IV /ODALTERNATE DAY
TAB. NICARDIA 10MG TID
TAB. LASIX 40MG PO/OD
TAB. OROFER X T PO/OD
TAB. NODOSIS 500MG PO/TID
TAB. SHELCAL-CT PO/OD

Advice at Discharge
FLUID RESTRICTION <1.5 LIT/DAY
SALT RESTRICTION <2GM/DAY
INJ. EPO 4000IU SC ONCE WEEKLY
INJ. IRON SUCROSE 100MG IN 100ML NS IV/OD ALTERNATE DAY
TAB. NICARDIA 10MG 
TAB. LASIX 40MG PO/OD
 TAB. OROFER X T PO/OD
 TAB. NODOSIS 500MG PO/TID
 TAB. SHELCAL-CT PO/OD


FOLLOW AT 3MONTHS
HB-10.1
MCV-87.6
MCH-35.7
MCHC-35.7
TLC -9700
PLT-1.8

AT THE END OF APRIL
HB-10.5
MCV-83.6
MCH-28.7
MCHC-29.7
TLC -8800
PLT-2.7

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