Case history -4

 20 September, 2021

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A 31 yr old patient , autodriver by occupation  presented to the opd with chief complaints of swelling of the legs and backache.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 months back then noticed backpain .

A year back ,  patient experienced headache , consulted a local RMP doctor where he was said that it was hypertension and was suggested with medication.

In the month of February, 2021

The patient noticed swelling of the legs, low urine output,  hence consulted a nephrologist. The patient was told that it is chronic kidney disease  due to raised creatinine levels and was suggested on dialysis..

Patient has undergone dialysis multiple times since February till date 16/9/21

4days back i.e on 16/9/21 patient also complained of severe backache and was suggested on MRI and X- ray of spine.

PAST HISTORY:

No history of diabetes , asthma , epilepsy, CAD.

Patient is a known case of hypertension since 1 year.

PERSONAL HISTORY:

Diet- mixed

Sleep- inadequate

Appetite- reduced 

Low urine output.

Addiction: occasionally takes alcohol.

FAMILY HISTORY:

No history of hypertension, asthma diabetes

No history of similar complaints in the family.

GENERAL EXAMINATION:

No cyanosis

No lymphadenopathy 

No clubbing

No icterus

Edema is present.

VITALS:

Temperature- 98.6

Pulse rate- 82 beats / min

BP - 150/90 mm Hg

Sp02- 96%

SYESTEMIC EXAMINATION:

CVS:

No thrills

S1S2 heard.

RESPIRATORY SYSTEM:

No wheeze

Position of trachea- central

Breath sounds- vesicular

ABDOMEN:

No tenderness

No palpable mass

CNS:

Speech- normal

No neck stiffness

INVESTIGATIONS:

LIVER FUNCTION TEST:

Total bilirubin- 0.63mg/dl

Direct bilirubin- # 0.22mg/dl

SGOT(AST)-18 IU/L

SGPT(ALT)- 13IU/L

Alkaline phosphatase- #129 IU/L

Total protein- #6.2 gm/dl

Albumin- # 3.2 gm/dl

RFT:

Urea: #50 mg/dl

Creatinine: # 6.7 mg /dl

Uric acid: 4.4 mg/dl

Calcium: 9.6 mg/dl

Phosphorous: 3.4 mg/dl

Sodium: 136 mEq/L

Potassium: 4.6 mEq/L

Chloride: # 96 mEq/L

SERUM IRON- 87 ug/dl

Diagnosis: chronic kidney disease on MHD, Vertebral osteomyelitis.

Treatment:

1. Fluid Restriction <1.5 L/day

2. Salt Restriction < 2g /day

3. T. Lasix 40 mg

4. T. Nicardia 20 mg

5. T. Arkamine 0.1 mg

6. T. Nodosis 500mg