CASE HISTORY:

 October 28, 2021

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A 45 yrs old male patient presented to the opd with chief complaints of swelling of legs, facial puffiness , burning micturition and fever.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back then developed 

1. Swelling of legs

2. Facial puffiness

3. Burning micturition

Patient was diagnosed as AKI on CKD and dialysis was initiated.

Patient has undergone 5 sessions of dialysis

Patient is a known case of hypertension and diabetes. Hypothyroidism since 6 months

PAST HISTORY:

Patient is a known case of hypertension and diabetes, hypothyroidism.

No history of any surgeries in the past.

No history of tuberculosis, asthma, CAD

PERSONAL HISTORY:

Appetite - normal

Sleep -normal

Diet-mixed

Bowel movement- regular

No addictions

FAMILY HISTORY:

No history of similar complaints in the family 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative

No cyanosis

No lymphadenopathy

Pallor is seen

No icterus

Pedal edema is seen

VITALS:

Temperature: 98.4 degrees F

BP: 140/90 mm of Hg

Pulse rate: 84 beats/min

Respiratory rate: 24 /min

SYSTEMIC EXAMINATION:

CVS:

No thrills 

S1S2 heard

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Position of trachea- Central

Breath sounds- Vesicular

ABDOMEN-

Shape of abdomen- Scaphoid

No tenderness 

No palpable mass

CNS:

Level of consciousness- conscious

Speech -normal

No neck stiffness

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS:

CKD on MHD

History of hypertension, diabetes, hypothyroidism

TREATMENT:

T. Lasix

T.Nicardia

T. Met-XL

T. Thyronorm

T. Livogen