l65year old male

DATE OF DISCHARGE -10/06/24
Diagnosis
CKD STAGE 5 INITIATED ON MHD K/C/O HYPERTENSION
 CHIEF COMPLAINTS:
PATIENT CAME WITH COMPLAINTS OF SHORTNESS IF BREATH SINCE 1 WEEK SWELLING OF BOTH LOWER LIMBSSINCE 1 YEAR PAIN ABDOMEN SINCE 1 YEAR

HISTORY OF PRESENT ILLNESS:
PATIENT WAS APPARENTLY ASYMPTOMATIC 1 YEAR AGO THEN HE DEVELOPED COMPLAINTS OF SHORTNESS OF BREATH SINCE 1 WEEK WHICH IS MORE WHILE WALKING AND RELIEVED ON RST . NO PND/NO ORTHOPNEA /NO PALPITATIONS/NO CHEST PAIN . SWELLING OF BOTH LOWER LIMBS IS GRADING IN ONSET SINCE 1 YEAR WHICH IS GRADE 2 , 3 .
NO H/O FEVER , NO H/O TRAUMA / NO H/O VOMITING/ DIARRHOEA . PAIN ABDOMEN IS SINCE 1 YEAR ASSOCIATED WITH DECREASE IN APPETITE .
 PAST HISTORY :
K/C/O HTN SINCE 1 YEAR ON NICARDIA 20 MG NO H/O DM /TB/ ASTHMA/EPILEPSY

 PERSONAL HISTORY
DIET :MIXED
APPETIET: NORMAL
BOWEL AND BLADDER: REGULAR AND NORMAL
ADDICTIONS : ALCOHOL REGUALAR STOPPED 3 YEARS BACK @ 30 ML /DAY

GENERAL EXAMINATION :
PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING
AT ADMISSION
TEMP:97.5F
PR:92 BPM
RR:16CPM
BP:160/100mmHg
SPO2:96@RA 2L 02
SYSTEMIC EXAMINATION
CVS:S1 S2+ , NO MURMURS
RS:BAE+, NVBS+
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 +1 +1
KNEE +2 +2
ANKLE +1 +1


Investigation

CBP ON 3/6/24
HB 9.2GM/DL
TC 7,200
MCV-88.9
MCH-28.5
MCHC-32.7
PLT3.10

SMEAR NORMOCYTIC NORMOCHROMIC

S.IRON -67
S FERRITIN-330

RFT ON 3/6/24
UREA 100 MG/DL
CREATININE 7.5 MG/DL
UA 5.4 MMOL/L
CA+2 9.2 MG/DL
P 5 MG/DL
NA+ 136 MMOL/L
K+ 4.6 MMOL/L
CL- 101 MMOL/L
HIV NON REACTIVE
HBSAG NEGATIVE
HCV NON REACTIVERFT 

 (LFT) 03-06-2024 
Total Bilurubin0.55 mg/dl
Direct Bilurubin0.20 mg/dl
SGOT(AST)10IU/L
SGPT(ALT)10 IU/L
ALKALINE PHOSPHATASE260 IU/L
TOTAL PROTEINS6.5gm/dl
ALBUMIN3.8 gm/dl


USG WAS DONE ON 3/6/24
IMPRESSION:
B/L POLYCYSTIC KIDNEY DISEASE WITH RAISED ECHOGENECITY OF KIDNEYS


2D ECHO WAS DONE ON 4/6/24
IMPRESSION:
EF 53%
MILD AR + , MILD TR + WITH PAH ; TRIVIAL MR+
RWMA + ANT WALL HYPOKINESIA
NO AS/MS
FAIR LV SYSTOLIC FUNCTIONS
GRADE 1 DIASTOLIC DYSFUNCTION
NO LV CLOT 

COURSE IN THE HOSPITAL
PATIENT WAS ADMITTED WITH ABOVE MENTIONED COMPLAINS, EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS, IN VIEW OF DERANGED RENAL PARAMETERS NEED FOR HAEMODIALYSIS WAS EXPLAINED AFTER TAKING DUE CONSENT. RIGHT IJV CATHETERIZATION WAS DONE AND 4 SESSIONS OF HAEMODIALYSIS WAS DONE. PATIENT IS HAEMODYNAMICALLY STABLE AND DISCHARGED PLAN FOR AV FISTULA EXPLAINED 

Treatment Given(Enter only Generic Name) 
1. FLUID RESTICTION <1.5 LTR/DAY. 
2. SALT RESTRICTION <2G/DAY. 
3.TAB NICARDIA 10MG BD 
4. TAB SHELCAL CT 500 mg PO/OD 
5. TAB LASIX 20 mg PO/BD
 6. TAB. NODOSIS 500 mg PO/OD
 7. TAB. OROFER XT PO/OD 0-0-1 
8. INJ. EPO 4000 IU S/C WEEKLY
 9.TAB PAN 40 MG PO/OD 
10. TAB AMLODIPINE 10MG PO/BD 


Advice at Discharge
1.FLUID RESTICTION <1.5 LTR/DAY
 2. SALT RESTRICTION <2G/DAY
 3.TAB AMLODIPINE 10MG PO/BD
 4. TAB SHELCAL CT 500 mg PO/OD 
5. TAB LASIX 20 mg PO/BD 
6. TAB. NODOSIS 500 mg PO/OD 0-1-0 
7. TAB. OROFER XT PO/OD 0-0-1 
INJ. EPO 4000 IU SC ONCE WEEKLY
INJ.IRON SUCROSE 1AMP IN 100ML NS IV OD ON ALTERNATE DAY 

FOLLOW UP AFTER 3MONTHS 
HB-10.0
MCV -78.2
MCH -26.3
MCHC -29.2
TLC -6400
PLT-3.1

FOLLOW UP AFTER THE END OF THESIS 
MARCH - 
HB -10.2
MCV -77.5
MCH -27.3
MCHC -30.1
TLC -7200
PLT -2.98


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