Case Study 8
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December 09 , 2021
A 40 year old male patient came to OPD for dialysis
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6 months
back then he noticed decrease in urine output ,
facial puffiness , pedal edema , swelling of arms
and legs , nausea , vomiting , constipation ,
abdominal discomfort then he went to a hospital in
khammam , where investigations were done then
he advised for advised for admission but he denied
and joined kims where he presented with fluid
overload and uremic symptoms then he started
MHD through right femoral access .
He also has ulcer on the left foot , he got that
during farming where a stone pressed against the
foot and a toe got amputated and then he took
Ayurvedic medication after that he lost another
toe . The foot was diagnosed to be diabetic foot .
PAST HISTORY
K/C/O DM since 16 years and he's on insulin
medication
K/C/O Hypertension since 6 months and he's on
medication
No K/C/O TB
PERSONAL HISTORY
Appetite - Normal
Diet - Mixed
Sleep - Inadequate
Bowel and bladder movements - Regular
Allergies - No known allergies
Habits - occasional alcoholic
FAMILY HISTORY
No significant family history
ON GENERAL EXAMINATION
Patient is conscious , coherent and cooperative
No pallor , icterus and cyanosis
No lymphadenopathy
No pedal edema
Temperature - 98.4
Pulse rate - 81 bpm
Blood pressure - 140/90 mmhg
Respiratory Rate - 21 cpm
SpO2 - 97 %
SYSTEMIC EXAMINATION
CVS:
S1 S2 heard
No murmurs
No thrills
RESPIRATORY SYSTEM:
BAE +
NVBS +
PER ABDOMEN
Soft
Non tender
CNS:
NFND
DIAGNOSIS
CKD on MHD
4. Tab shelchal CT po/bd
5. Tab orofer XT po/bd
6. Tab Cap bio - D3 po/bd
7. Inj. Erythropoitin 4000 IU s/c weekly twice
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