Case history 4

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A 60 year male Old patient presented to opd with chief complaint of  weakness and swelling of legs. 

History of present illness:

Patient was apparently alright 1year ago and then he developed swelling of legs and weakness associated with fever. 

Pain is moderate

Shortness of breath is present. 

Patient has undergone Haemodyalisis. 

History of past illness:

Patient was suffering from hypertension since 7 months. Patient is not a known case of diabetes. 

Personal history:

Patient follow mixed diet. 

Appetite-normal

Bowel and bladder moments:  normal

Micturition : Reduced. 

Patient has not undergone any major surgeries. 

Patient had a habit of drinking alcohol, but not smoke. 

Drug history:

No allergy to any drugs. 

Family history:

No similar complaint seen in any member of the family. 

General examination:

Patient is coherent, conscious, and co-operative. He is moderately built and nourished. 

Cyanosis-absent

Pedal edema - present, pallor-present. 

No icterus

No clubbing

No LYMPHADENOPATHY

Vitals:

Temperature:98.4 f

Pulse rate :84/min

Respiratory rate:24/min

B. P:130/70mmHg

Spo2:98%

Grbs:136mg/dl

SYSTEMIC EXAMINATION

CVS:

:No thrills,

No murmur present

 Cardiac sounds - S1, S2 heard

Respiratory system:

No Dyspnoea

No wheeze

 Position of trachea :central

 Vesicular breath sounds are heard

CNS:

conscious-present

Reflexes are present

Speech is normal

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

CKD ON MHD. 

TREATMENT PLAN:

Tab Nudosis 500mg oral -OD 

Tab Shelcal oral-OD

Tab Orofer XT oral -BD

Inj Erythropoietin 4000 IV