70year old male

DIAGNOSIS - CHRONIC RENAL FAILURE

CHEIF COMPLAINTS
C/O DECREASED URINE OUTPUT SINCE 2 DAYS 
C/O SOB SINCE 2 DAYS
 HOPI 
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK THEN HE DEVELOPED DECREASED URINE OUTPUT SINCE 2 DAYS BURNING MICTURITION- NEGATIVE
SOB SINCE 2 DAYS; GRADE II MMRC; ORTHOPNEA -, PND -, CHEST PAIN PEDAL EDEMA SINCE 3 DAYS; PITTING TYPE; EXTENDING UPTO KNEE N/H/O FEVER,COLD,COUGH,ALLERGIES N/H/O CHEST PAIN,PALPITATIONS,SWEATING N/H/O ABDOMINAL PAIN,NAUSEA,VOMITING,DIARRHOEA N/H/O BURNING MICTURITION
N/K/CO HTN,DM II,TB,EPILEPSY,ASTHMA,CVA,CAD

 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: 90/60 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

HB -8.9
MCV 79.4
MCH 28.5
MCHC 29
TLC 8900
PLT  2.45

S.IRON -58
S.FERRITIN -176.4

RFT 16-08-2024 
UREA 180 mg/dl
CREATININE 6.3 mg/dl
URIC ACID 10.0mmol/L
CALCIUM 9.9 mg/dl
PHOSPHOROUS 3.8 mg/dl
SODIUM 126 mmol/L
POTASSIUM 3.7mmol/L
.CHLORIDE 106 mmol/L

LFT 
Bilurubin 2.42 mg/dl
Direct Bilurubin 0.65 mg/dl
SGOT(AST) 28 IU/L
SGPT(ALT) 19 IU/L
ALKALINE
PHOSPHATASE 616 IU/L
TOTAL PROTEINS 6.7 gm/dl
ALBUMIN 3.0 gm/dl
A/G RATIO 0.85

CUE -ALB -+ 
SUGAR -NIL
PUS CELLS 2 -4

2D ECHO -
EF -59% 
NO RWMA
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)
1)FLUID RESTRICTION <1.5L/DAY
2)SALT RESTRICTION <2 G /DAY
3) INJ.EPO 4000 IV/SC/ONCE WEEKLY 
4)TAB NODOSIS 500MG PO/BD
5)TAB SHELCAL CT PO /OD 
6)TAB LASIX 40MG PO/BD
7)TAB.AZITHROMYCIN 500MG PO/OD 8)TAB.AUGMENTIN 625 MG PO/BD
 9)TAB. OROFER XT PO/OD 10)SYP.GRILLINCTUS 15ML PO/BD 11)SYP.CREMAFFIN 10 ML PO/TID

Advice at Discharge
1)FLUID RESTRICTION <1.5L/DAY 
2)SALT RESTRICTION <2 G /DAY
 3)TAB NODOSIS 500MG PO/BD 
4)TAB SHELCAL CT PO /OD 
5)TAB LASIX 40MG PO/BD
 6TAB. OROFER XT PO/OD
 7)SYP.GRILLINCTUS 15ML PO/BD 8)SYP.CREMAFFIN 10 ML PO/TID

FOLLOW UP AFTER 3MONTHS 
HB -9.6
MCV -78.2
MCH -28.4
MCHC -29.3
TLC 7200
PLT. 2.10

END THE END OF MY STUDY - PATIENT HAD EXPIRED AT HOME ? ACUTE PULMONARY ODEMA 

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