38year old male

Diagnosis
CHRONIC RENAL FAILURE
HYPERTERNSIVE URGENCY(RESOLVED) DENOVO HTN

 CHIEF COMPLAINTS : 
C/O SOB SINCE 15 DAYS C/O DRY COUGH SINCE 15 DAYS
 HOPI :
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL 15 DAYS AGO THEN PATIENT DEVELOPED SHORTNESS OF BREATH (GRADE II-III) WHICH IS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE ASSCIATED WITH DRY COUGH AND ORTHOPNEA (NOW DECREASED), HEADACHE, BLURRING OF VISION , PEDAL EDEMA AND DECREASED URINE OUTPUT.
NO C/O FEVER, COLD, BURNING MICTURITION, VOMITINGS, LOOSE STOOLS, PAIN ABDOMEN

PAST HISTORY :
H/O POLIOMYELITIS OF RIGHT LOWER LIMB SINCE CHILDHOOD N/K/C/O HTN,DM,CAD,CVA,TB,ASTHMA,EPILEPSY,THYROID DISORDERS 

PERSONAL HISTORY
DIET: MIXED
APPETITE: NORMAL
SLEEP: ADEQUATE
BOWELS :REGULAR
ADDICTIONS: NIL
ALLERGIES: NIL

GENERAL EXAMINATION:
No PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA
BP:220/150MMHG
PR:102BPM
RR:20CPM
SPO2:99@ RA
GRBS: 103 MG%
SYSTEMIC EXAMINATION:
CVS:S1 S2 HEARD ,NO MURMURS
RS:BAE PRESENT
CNS: NFND
P/A:SOFT,NT
CNS- CONSCIOUS, PUPILS-NSRL
MOTOR SYSTEM : WASTING OF RIGHT LOWER LIMB
GCS-15/15 E4V5M6
REFLEXES BICEPS TRICEPS SUPINATOR KNEE ANKLE
RIGHT 2+ 2+ 2+ - -
LEFT 2+ 2+ 2+ 2+ +
FINGER NOSE AND KNEE HEEL INCOORDINATION: NO
Investigation

HB -9.8
MCV -80
MCH 27.5
MCHC -33.2
TLC -8700
PLT -2.1

S.IRON -80
S.FERRITIN- 210

CUE 
ALBUMIN ++++
SUGAR NIL
PUS CELLS 4-6
RED BLOOD CELLSNil 

 (LFT) 
TotalBilurubin 1.59 mg/dl
Direct Bilurubin 0.43 mg/dl
SGOT(AST) 21 IU/L
SGPT(ALT) 10 IU/L
ALKALINE
PHOSPHATASE 151 IU/L
TOTAL PROTEINS 6.4 gm/dl
ALBUMIN 3.8 gm/dl
A/G RATIO 1.46

RFT
UREA 137 mg/dl
CREATININE 6.0
mg/dlURIC ACID 5.8 mmol/L
CALCIUM 8.8 mg/dl
PHOSPHOROUS 5.0 mg/dl
SODIUM 140mmol/L
POTASSIUM 3.2 mmol/L.
CHLORIDE 105 mmol/L


USG DONE ON 15-10-2024
LIVER : N S/E, NO F/L, NO IHBRD
PANCREAS AND SPLEEN : N S/E
RT.KIDNEY : 8X3.6 CM
LT KIDNEY : 8.2X 3.2CM
AORTA IVC : NORMAL
NO LYMPHADENOPATHY
U.BLADDER : DISTENDED
V-U JUNCTION : INTERNAL ECHOES +
PROSTATE : 20 CC N S/E
IMPRESSION :
GRADE I-II RPD CHANGES IN B/L KIDNEYS


2D ECHO
EF -60%
MILD TO MODERATE MR, MILD AR, TRIVIAL TR
NO RWMA, NO AS/MS, CONCENTRIC LVH
GOOD LV SYSTOLIC FUNCTIONS
NO DIASTOLIC DYSFUNCTION, NO LV CLOT

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 
1.FLUID RESTRICTION<1.5 L/DAY
 2.SALT RESTRICTION<2 GM/DAY 
3.INJ.EPO 4000 IU SC/WEEKLY ONCE 4.TAB.NICARDIA 20MG PO/TID 1-1-1 5.TAB.MET XL 50MG PO/OD 1-0-0 6.TAB.NODOSIS 500MG PO/BD 1-0-1 7.TAB.SHELCAL-CT PO/OD 0-1-0 8.TAB.OROFER XT PO/OD 1-0-0 9.TAB.DYTOR 10MG PO/BD 1-0-1
9.INJ.IV IRON 1AMP IN 100ML NS IV/OD ALTERNATE DAY

 Advice at Discharge
FLUID RESTRICTION<1.5 L/DAY 
SALT RESTRICTION<2 GM/DAY 
TAB.NICARDIA 20MG PO/TID 1-1-1
 TAB.MET XL 50MG PO/OD 1-0-0 TAB.NODOSIS 500MG PO/BD 1-0-1 TAB.SHELCAL-CT PO/OD 0-1-0
 TAB.OROFER XT PO/OD 1-0-0
 TAB.DYTOR 10MG PO/BD 1-0-1 
INJ.EPO 4000 IU SC/WEEKLY ONCE
.INJ. IRON 1AMP IN 100ML NS IV/OD ALTERNATE DAY


FOLLOW UP AFTER 3MONTHS 
HB-8.2
MCV -79.2
MCH-27.1
MCHC-32.1
TLC -7800
PLT-1.98

AT THE END OF APRIL 
HB-7.8
MCV -77.2
MCH-26.1
MCHC-31.2
TLC -8900
PLT-2.0


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