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50 years Years old male came to OPD with cheif complaints of shortness of breath since 10 days.
Complaints of decreased urine output,nausea,B/L pedal edema and constipation since 10 days.
Patient was aparently asymptomatic 15 years back, then developed B/L pedal edema , shortness of breath and was brought to our hospital 1 session of HD done.Patient was diagnosed with CKD 15 years back and was treated conservatively(on and off).
Now again 10 days back he came to OPD.
Past History :-
K/C/O HTN since 10 months and on regular medications.
Not a known case of DM , asthama , TB , Thyroid , epilepsy.
Personal History :-
Diet : mixed
Apetite : decreased since 10 days.
Sleep : adequate.
Bowel movements : irregular
Decreased urine output.
No any addictions.
On examination, patient is C/C/C .
Pallor present.
B/L pitting edema present till knees.
No cyanosis , icterus, clubbing , lymphadenopathy.
Temperature - 98.5*F
PR - 112/ min
RR - 18cpm
BP - 110/90 mmhg
Spo2 - 99% at RA
Grbs - 115 mg%
CVS :- S1 , S2 heard
RS - BAE present
P/A - soft and non tender
CNS - No focal Neurological deficet.
RFT :-
Serum Albumin :-
USG :-
Serology:-
Serology :-
Serology:-
CBP:-
CUE:-
Provisional diagnosis :-
Chronic kidney disease with Polycystic kidney disease and K/C/O HTN since 10 months.
Updates
(18/12/21)Day 2 :
Urea :- 219 mg/dl
Creatinine : 17.5 mg/dl
Hb : 5.2 gm%
1 session of HD was performed on 18th along with transfusion of 1 unit of PRBC.
S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.
O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID
(19/12/21 )day 3:
Urea : 109 mg/dl
Creatinine : 11.3 mg/dl
Hb : 7.4 gm%
S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.
O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID
(20 /12/21)Day 4:
Urea : 115 mg/dl
Creatinine : 11.2 mg/dl
Hb : 6.8 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.
S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.
O :-
BP - 160/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID
Day 5 (21/12/21)
Urea : 42 mg/dl
Creatinine : 4.9 mg/dl
Hb : 8.4 gm%
1 session of HD was done.
S :-
B/L Pedal edema present.
Decreased urine output.
O :-
BP - 150/80 mmhg
PR - 83 bpm
Temp - afebrile
RR -17cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID
Day 6 (22/12/21)
Urea : 36 mg/dl
Creatinine : 2.9 mg/dl
Hb : 9.1 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.
S :-
B/L Pedal edema present.
Decreased urine output.
Nausea present.
O :-
BP - 130/80/90 mmhg
PR - 82 bpm
Temp - afebrile
RR -16cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
10) TAB ARKAMINE 0.1MG PO/OD
11) TAB ZOFER 4MG PO/TID
Day 7 (23/12/21)
Hb : 9.8%
S :-
B/L Pedal edema present.
Decreased urine output.
O :-
BP - 130/80 mmhg
PR - 81 bpm
Temp - afebrile
RR -17cpm
Spo2 - 99% at RA
P :-
1) Fluid restriction less than 1L / day
2) Salt restriction less than 2.4 gm/day
3) TAB. LASIX 40MG PO/TID
4) TAB. NICARDIA 20 MG PO/BD
5) TAB OROFER-XT PO/OD
6) TAB NODOSIS 550MG PO/BD
7) TAB SHECAL 500MG PO/OD
8) INJ ERYTHROPOIETIN 4000IU S/C WEEKLY ONCE
9) INJ IRON SUCROSE 2 AMP IN 100ML NS IV DURING DIALYSIS
