37year old female

DOA-21/08/2024
DOD-19/09/2024

DIAGNOSIS 
CKD ON MHD
K/C/O DM II 10 YEARS K/C/O HTN SINCE 4 YEARS 

CHIEF COMPLAINTS
C/O PEDAL EDEMA SINCE 1 MONTH C/O BURNING MICTURITION SINCE 1 MONTH

 HOPI
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO THEN SHE DEVELOPED PEDAL EDEMA SINCE 1 MONTH PITTING TYPE , EXTENDING UPTO KNEE BURNING MICTURITION SINCE 1 MONTH NO WHITISH DISCHARGE, NON BLOOD STAINED NO H/O FEVR , COL, COUGH, ALLERGIES NO H/O ABDOMINAL PAIN
NO H/O VOMITING , NAUSEA, LOOSE STOOLS

 PAST HISTORY
K/C/O DM II SINCE 10 YEARS ON INJ HAI SC 20 U -O-20U AND TAB.GLICLEZIDE 60 MG PO BD K/C/O HTN SINCE 4 YEARS ON TAB CINOD 10 MG PO BD N/K/C/O , TB , ASTHMA, THYROID ABNORMALITIES, CAD, CVA
H/O CARCINOMA LEFT BREAST OPERATED ON 26 / 3 /21 AND CHEMOTHERAPY 4 YEARS BACK
PERSONAL HISTORY 
APPETITE - NORMAL
DIET - MIXED
BOWEL AND BLADDER - DECREASED URINE OUTPUT
NO KNOWN ALLERGIES
ADDICTIONS- TOBACCO
GENERAL EXAMINATION :
PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE.
NO SIGNS OF PALLOR,ICTERUS,CYNOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA OF
FOOT
TEMP: 98.2 F
BP:130/60 MMHG
RR: 20 CPM
PR: 98 BPM
SPO2 98 AT RA
SYSTEMIC EXAMINATION:
CVS: S1S2 HEARD. NO MURMURS.
RS: BAE+. TRACHEA- CENTRAL.
P/A: SOFT,NON-TENDER.
CNS: NFND
Investigation
HB-8.6
MCV-78.2
MCH-27.2
MCHC-30.1
TLC 9700
PLT -2.43

PERIPHERAL SMEAR -NORMOCYTIC NORMOCHROMIC 

S.IRON-65MICROGM /DL
S.FERRITIN-187NG/ML


LFT
Total Bilurubin 0.57 mg/dl
Direct Bilurubin 0.18 mg/dl
SGOT(AST) 11 IU/L
SGPT(ALT) 22 IU/L
ALKALINE PHOSPHATASE 258 IU/L
TOTAL PROTEINS 7.2 gm/dl
ALBUMIN 3.58 gm/dl
A/G RATIO 0.99

RFT
UREA -60
CREAT -5.0
NA+ -136
K+ -3.9
CL-98

COMPLETE URINE EXAMINATION 
 ALBUMIN ++++ 
SUGAR ++  PUS CELLS 5-6
RBC -NIL

2D ECHO
EF -59% 
CONCENTRIC LVH
NO RWMA
GRADE 1 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 LESS THAN 1.5LITRES/DAY
 SALT RESTRICTION LESS THAN 2G/DAY
 TAB. NICARDIA 20 MG PO BD
 TAB. NODOSIS 500 MG PO BD 
TAB. OROFER XT PO OD 
TAB. SHELCAL CT PO OD 
INJ EPO 4000 IU S/C WEEKLY ONCE
INJ IV IRON SUCROSE 1AMP IN 100ML NS IV/OD ALTERNATE DAY

ADVICE AT DISCHARGE 
FLUID RESTRICTION LESS THAN 1.5L/DAY
SALT RESTRICTION LESS THAN 2G/DAY TAB. NICARDIA 20 MG PO BD 
TAB. NODOSIS 500 MG PO BD 
TAB. OROFER XT PO OD 
TAB. SHELCAL CT PO OD
INJ EPO 4000 IU S/C WEEKLY ONCE
INJ IV IRON SUCROSE 1AMP IN 100ML NS IV/OD ALTERNATE DAY


FOLLOW UP AFTER 3MONTHS 
HB-9.2
MCV-79.2
MCH-27.3
MCHC-30.1
TLC 8600
PLT -2.41

AT THE END OF APRIL 
HB-8.9
MCV -78.7
MCH-27.1
MCHC-28.1
TLC -7800
PLT -1.98

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