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9.

 Case History and Clinical Findings

C/O ALTERED SENSORIUM SINCE 1 DAY

HOPI :

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN HE DEVELOPED

ANASARCA AND WENT TO LOCAL HOSPITAL WHERE IT WAS DIAGNOSED AS CKD

UNDERWENT 6 SESSIONS OF DIALYSIS

IN THE LAST DIALYSIS PAT WAS UNABLE TO LIFT HIS LEG ON WALKING SINCE 1 DAY .

PATIENT WAS IRRELAVENT TO WALK

PAST HISTORY ;

K/C/O DM 2 SINCE 10YEARS ON MEDI

K/C/O HTN SINCE 20DAYS AND ON NICARDIA 20 MG

N/K/C/O ASTHMA , EPILEPSY , TB , CAD , THYROID DISORDERS

PERSONAL HISTORY :

DIET :MIXED

APPETITE : GOOD

SLEEP : ADEQUATE

BOWEL: REGULAR

BLADDER HABITS : REGULAR

GENERAL EXAMINATION : PATIENT IS CONSCIOUS , COHERENT , COOPERATIVE PALOR +

PEDAL EDEMA +

NO SIGNS OF CLUBBING , ICTERUS , CYANOSIS , LYMPHEDNOPATHY

VITALS :

TEMP : 96.8 F

PR : 100 BPM

BP : 160/90 MMHG

GRBS : 124 MG / DL

SPO2 : 98 %

RR : 28 CPM

SYSTEMIC EXAMINATION :

CVS : S1 , S2 HEARD , NO MURMURS

RS : BAE + , NVBSHEARD

PA : SOFT , NON TENDER , BS +

CNS : NFAD

Investigation

Anti HCV Antibodies - RAPID06-10-2023 09:07:AM

Non Reactive

HBsAg-RAPID06-10-2023 09:07:AMNegative COMPLETE URINE EXAMINATION (CUE) 06-10-2023

09:07:AM COLOUR

Milky white

APPEARANCE

Cloudy

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS Nil

PUS CELLS

plenty

EPITHELIAL CELLS

1-2

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

Nil

LIVER FUNCTION TEST (LFT) 06-10-2023 09:07:AM

Total Bilurubin

0.53 mg/dl

Direct Bilurubin

0.16 mg/dl

SGOT(AST)

25 IU/L

SGPT(ALT)

19 IU/L

ALKALINE PHOSPHATE

204 IU/L

TOTAL PROTEINS

6.0 gm/dl

ALBUMIN

2.6 gm/dl

A/G RATIO

0.74

RFT 06-10-2023 09:07:AM UREA 58 mg/dl

CREATININE

4.9 mg/dl

URIC ACID

3.4 mg/dl

CALCIUM

9.5 mg/dl

PHOSPHOROUS

3.2 mg/dl

SODIUM

132 mEq/L

POTASSIUM

3.9 mEq/L

CHLORIDE99 mEq/LRFT 31-10-2023 07:45:PM UREA

104 mg/dl

CREATININE

7.4 mg/dl

URIC ACID

4.9 mg/dl

CALCIUM

8.0 mg/dl

PHOSPHOROUS

2.4 mg/dl

SODIUM

129 mEq/L

POTASSIUM

4.1 mEq/L

CHLORIDE

98 mEq/L

RFT 01-11-2023 06:30:AM UREA

95 mg/dl

CREATININE

6.7 mg/dl

URIC ACID

6.2 mg/dl

CALCIUM

9.2 mg/dl

PHOSPHOROUS

5.6 mg/dl

SODIUM

136 mEq/L

POTASSIUM

4.2 mEq/L

CHLORIDE

101 mEq/L


Diagnosis

CKD ON MHD


Treatment Given(Enter only Generic Name)

FLUID RESTRICTION <1LITER/DAY

SALT RESTRICTION <1GM/DAY

TAB NICARDIA 20MG PO/OD

TAB OROFER XT PO/OD

INJ EPO 4K S/C TWICE WEEK

INJ IRON SUCROSE IN 100ML NS IV TWICE WEEKLY


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