General medicine case-10

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A 32 yrs male patient came to OPD on 2/11/21  from vellanki with the complaint of pedal edema since 3 months,sob since 2 months, decreased urine output since 3 months.

History of present illness :- 

-Patient is asymptomatic 3 months back ,then he developed pedal edema .

-Patient also has decreased urine output since 3 months and sob since 2 months .

-Patient also had episode of seizure on 19/9/21 in the evenging around 4 to 5 pm.

Daily routine :- 

-Patient wakeup around 5am in morning and go to work around 7 to 8 am by having breakfast  and come to home around 3 to 5 pm in evenging.

-On the day of seizure he did not went to work .

History of past illness:- 

- Has history of hypertension ,diabetes since 2 yrs .

-No history of asthma, epilepsy, previous surgery , lymphadenopathy .

Personal history :- 

- Diet :- mixed 

-Appetite :- normal 

- sleep :- normal 

-Bowel and bladder movements :- normal .

Decreased urine output .

Addictions :- No history of alcohol intake and smoking .

Family history :- 

No history of similar complaints in family members.

Drug history :- 

No history of allergy to known drugs .

General examination :- 

-Patient is conscious, coherent, cooperative and well oriented to surroundings.

-Patient has swelling of left hand around wrist and palm and also pain of left hand  due to dialysis .

- Clubbing of left hand fingers .

-  No cyanosis.

-Pallor present .

Vitals :- 

Temperature :- Afebrile 

Pulse rate :- 90 beats / min 

Respiratory rate :- 15 cycles / min 

Bp :- 140 /80 mmHg 

Systemic examination :- 

-CVS :- S1,S2 +, no murmurs heard 

-Respiratory system :- Bilateral air entry is normal .

- Abdomen :- No  Tenderness at the lower abdomen region .

- CNS :- Patient is conscious, coherent, cooperative and well oriented to surroundings. Speech is normal 

Investigations :- 

Diagnosis :- chronic kidney disease on maintenance dialysis 

Treatment :- 

Fluid restriction <1.5 L/day 

Salt restriction <2g /day 

Tab Lasix 40 mg PO/BD 

Tab Nodosis 500 mg PO/BD 

Inj HAI s/c 6U TID 

Tab BIOD3 500 mg PO/BD 

Inj ERYTHROPOIETIN 4000 IU /SC / weekly once