A 37 yr old patient suffering from CKD with HTN and anemia secondary to CRF

 A 37 year old male patient who is farmer by occupation and a resident of yacharam, Nalgonda.

CHIEF COMPLAINTS-

Patient was admitted to undergo dialysis procedure 

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptomatic 25 days back nd later he developed cough and shortness of breath which lasted for 10 hours after which he was admitted into nearby private hospital in Nalgonda where he was diagnosed with chronic kidney disease and he was suggested to go for dialysis procedure over there. He had undergone 6 dialysis procedures in that hospital.

 Due to the high expenses for dialysis over there, the family members shifted the patient to our hospital and till now he had undergone 3 procedures over here. He developed a low grade fever, cough, shortness of breath of grade 2 to 3 and ascites initially when he got admitted in our hospital and all of them were insidious in onset and gradual in progression and were relieved after dialysis was performed.

On 30-11-21, patient suffered from an episode of GTCS seizure which lasted for 15 sec. Patient bit his tongue during the episode and involuntary micturation along with post ictal confusion were present. No froth on the mouth was noticed.

PAST HISTORY -

Patient is suffering from hypertension since past 25 days.

Not a known case diabetes/thyroid /tuberculosis/epilepsy/asthma

FAMILY HISTORY -

No relevant family history

No known cases of diabetes/hypertension/ tuberculosis/asthma/epilepsy/thyroid

PERSONAL HISTORY -

Appetite is decreased

Mixed diet 

Sleep is not adequate 

Bowel and bladder movements are normal

No known allergies

Patient consumes alcohol occasionally.

PHYSICAL EXAMINATION -

GENERAL 

Patient is conscious ,coherent and cooperative 

Patient is well oriented to time and place

Moderately built and moderately nourished

Pallor:absent

Icterus: present

Clubbing:absent

Cyanosis:absent

Lymphadenopathy: absent

Edema: absent

VITALS

Temperature: afebrile

Pulse: 88 bom

Respiratory rate: 22 per min

Blood pressure: 100/90

SpO2 at room air: 99%

SYSTEMIC EXAMINATION 

Cardiovascular system

s1 and s2 heard ,no murmurs 

Respiratory system

Central position of trachea 

Vesicular breath sounds

No wheeze,no dyspnea

Abdomen

Scaphoid shape

Bowel sounds present

No tenderness

No palpable masses

PROVISIONAL DIAGNOSIS -

CKD on MHD with HTN and anemia secondary to CRF

INVESTIGATIONS -

RFT - 

LFT -

Complete urine examination -

Haemogram -

ECG -

On 24-11-21

On 30-1-21

TPR graphic sheet -

 TREATMENT -