-47year old male


47 year old male

DOA -7/11/2024
DOD-15/11/2024

Diagnosis
CKD SECONDARY TO ?HYPERTENSIVE NEPHROPATHY 
K/C/O HTN

CHEIF COMPLAINTS:
C/O B/L LEGS SWELLING SINCE 1 MONTH
 C/O SOB SINCE 1 MONTH COUGH
GENERALISED BODY ITCHING ABDOMINAL BLOATING SENSATION 

HISTORY OF PRESENTING ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH AGO , THEN HE DEVELOPED COUGH , NON PRODUCTIVE, A/W SOB GRADE II-III C/O PEDAL EDEMA G-III PITTING TYPE EXTENDING FROM KNEE TO ANKLE
C/O FACIAL PUFFINESS, ABDOMINAL BLOATING SENSATION NO C/O HEADAHCE, NAUSEA, VOMITING NO C/ CHEST PAIN , PALPITATIONS,PND NO C/O BURNING MICTURITION,LOOSE STOOLS 

PAST HISTORY:
K/C/O CKD 6 MONTHS ON MEDICATION 
K/C/O HTN 3 YRS
N/K/C/O/ ,DM CVA, CAD, TB, EPILEPSY 


GENERAL EXAMINATION :
PATIENT IS CONSCIOUS ,COHERENT , COPERATIVE
NO SIGNS OF PALLOR , ICTERUS, CYANOSIS, CLUBBING, LYMPH ADENOPATHY ,OEDEMA
OF FOOT.
TEMP: 98.3
PR: 89 BPM
RR: 18 CPM
BP: 160/80 MMHG

SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD. NO MURMURS
RS :TRACHEA- CENTRAL. BAE+
P/A- SOFT, NON- TENDER. BOWEL SOUNDS HEARD.
CNS: NO FOCAL NEUROLOGICAL DEFECTS.


Investigation
LFT-
Total Bilurubin 0.35 mg/dl
Direct Bilurubin 0.18mg/dl
SGOT(AST) 69 IU/L
SGPT(ALT) 75 IU/L
ALKALINE PHOSPHATASE 204 IU/L
TOTAL PROTEINS 5.4 gm/dl
ALBUMIN 3.23 gm/dl 
A/G RATIO 1.49

ABG-
PH -7.1
PCO2 -21.3
PO2-87.3
HCO3-6.1
S02-97.4

RFT
UREA 163 mg/dl
CREATININE 5.1 mg/dl
URIC ACID 6.1 mmol/L
CALCIUM
8.3 mg/dl
PHOSPHOROUS 4.4 mg/dl
SODIUM 136 mmol/L
POTASSIUM 5.5 mmol/L
CHLORIDE 105mmol/L

HEMOGRAM ON 12/11/24
HB- 4.8MG/DL
TLC-6,600
MCV -77.2
MCH -26.3
MCHC -27.3
PLATELETS-1.6

S.IRON -67
S.FERRITIN -98.3

2D ECHO -
EF-61% 
NO DIASTOLIC DYSFUNCTION 


INTERVENTIONS
ORAL IRON THERAPY -DAILY TAB.OROFER XT
IV IRON THERAPY -TWICE /WEEK
EPO -YES
EPO DOSING -ONCE/2WEEKS
PRBC TRANSFUSED -3
ADMISSION IN ICU -0



USG DONE 
IMPRESSION
B/L GRADE III RENAL PARENYMAL DISEASE
RT RENAL SIMPLE CORTICAL CYST
MODERATE ASCITIES
MODERATE B/L PLUERAL EFFUSION
MILD PERICARDIAL EFFUSION

Treatment Given(Enter only Generic Name)
1)FLUID RESTRICTION <1.5L/DAY
2)SALT RESTRICTION <2 G /DAY
3)INJ EPO 4000IU WEEKLY ONCE
4)TAB NODOSIS 500MG PO/BD
5)TAB SHELCAL CT PO /OD
6)TAB AKARAMINE 0.1MG PO/TID
7)TAB PRAZOSIN 2.5MG PO/BD
8)TAB. OROFER XT PO/OD
9)T. NICARDIA XR 30 MG PO/TID
10. T. DYTOR 2OMG PO/BD
11. LIQUID PARAFFIN FOR L/A BD 2WEEKS
12.MOMATE F CREAM FOR L/A
13. T. LORATIDINE 1MG PO/ OD X 1WEE

Advice at Discharge
1)FLUID RESTRICTION <1.5L/DAY 
2)SALT RESTRICTION <2 G /DAY 
3)INJ EPO 4000IU WEEKLY ONCE 
5)T. PCM 650 MG PO TID FOR 1 WEEK 
6)SYP ASCORYL 10ML PO TID FOR 1 WEEK 4)TAB NODOSIS 500MG PO/BD 
5)TAB SHELCAL CT PO /OD
 6)TAB ARKAMINE 0.1MG PO/TID 
7)TAB PRAZOSIN 2.5MG PO/BD 
8)TAB. OROFER XT PO/OD 
9)T. NICARDIA XR 30MG PO/TID 
10. T. DYTOR 20 MG PO/BD
11. LIQUID PARAFFIN FOR L/A BD 2WEEKS


HB AFTER 3MONTHS 
HB -7.1
MCV-79.3
MCH-28.1
MCHC-30.4
TLC -6600
PLT-1.75

HB AT THE END OF THESIS 
HB-6.7
MCV-78.2
MCH-27.6
MCHC -29.4
TLC-7800
PLT -1.8

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