Case history-2

 August 23, 2021

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Date of admission: 20/8/21

A 46 year old female patient agriculturer by occupation presented to the OPD with chief complaint of swelling in the right side of the leg.

History of present illness:

Patient was apparently asymptomatic 4 months back .

In the month of June(16.8.21) , patient noticed swelling of both the legs and was diagnosed with CKD, suggested on dialysis. Patient has undergone total 11 dialysis till 6/8/21

Patient presented to the OPD 3 days back i.e ( 20/8/21) with swelling in the right side of the leg . 

There is history of pain associated with swelling.

Past history:

No history of surgeries in the past.

Patient is a known case of diabetes since 3 years.

No history of asthma , epilepsy.

Personal history:

Appetite- normal

Sleep- adequate

Addictions- no  addictions

Family history:

No history of thyroid disorder, asthma, CAD ,diabetes, hypertension in the family.

General examination: 

Patient is conscious , coherent and cooperative

No pallor , no clubbing

Paedal edema is present

Vitals:

Temperature- afebrile

Pulse rate- 84bpm

BP- 90/60 mm Hg

Systemic examination:

CARDIOVASCULAR SYSTEM

S1 S2 heard

No thrills.

RESPIRATORY SYSTEM

Position of trachea- central

Breath sounds- vesicular

PER ABDOMEN:

Shape - scaphoid 

Tenderness- no

Hernial orifices- normal

CENTRAL NERVOUS SYSTEM

Level of consciousness - conscious

Speech- normal

Motor and sensory system- normal

Investigations:

RFT:

Urea:#45 mg/dl

Creatinine: # 2.3 mg/dl

Uric acid:# 7.9mg/dl

Calcium:10 mg/dl

Phosphorus : 3.7 mg/dl

Sodium:# 132 mEq/L

Potassium: # 3.4 mEq/L

Chloride: 105mEq/L

Provisional diagnosis:

CKD with idiopathic deep vein thrombosis

Treatment:

1.T. LASIX 20mg

2. T. Nodosis  500mg

3. T. ODOFER

4. SHELCAL

5. Inj. Erythropoietin 4000 IU/ SC/Weekly twice.

6. Inj.Iron sucrose / amp in 50ml

7. Inj. HAI S/C

8. Fluid restriction < 1.5 L/day

9. Salt  restriction < 4 gm/day.