CKD CASE

CASE SCENARIO 

Patient aged 62 yrs,toddy Tree climber by occupation came to opd with complaints
Of loss of appetite and nausea since one week,
Decreased urine output since 5 days
And SOB on exertion and B/L limb swelling since a week

HISTORY OF PRESENT ILLNESS

Since a week pt has loss of appetite and nausea 
SOB on exertion and B/L limb swelling since a week
Decreased urine output since 5 days


HISTORY OF PAST ILLNESS

Pt was apparently normal 4 yrs back then he developed weakness and pain of bilateral limbs and on medication with pain killers on which the pain was not subsided then xray of spine was done and pt was diagnosed with Decreased bone density (OSTEOPOROSIS)
Pt diagnosed with HYPERTENSION and on hypertensives
Not a k/c/o of DM,CAD

TREATMENT HISTORY 
Pt was on hypertensives and had a tablet daily once

PERSONAL HISTORY

Irregular bowel habit
Decreased urine output
Mixed diet 
Occasional alcohol drinker
Had smoking habit

PHYSICAL EXAMINATION 

Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

                       Icterus

Edema of feet is present 


VITALS


•Temp - 98.4F

•Pulse rate - 80 BPM

•RP - 20/min

•BP - 140/70 mm hg

•SPO2 - 96

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

Pt has Dyspnoea 

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

INVESTIGATIONS 

S.Creatinine -9.9 mg/dl

Blood Urea-149 mg /dl

Urine is albumin +










PROVISIONAL DIAGNOSIS 

CRF

TREATMENT 


Supportive treatment is given

●Tab LASIX 40 mg/BD

●Tab PAN 40mg /OD

●Tab NODOSIS 500 mg/OD

●Tab SHELCAL 500mg/OD

●Tab MVT

●BP/TEMP/PR/SP02 monitoring 4th hrly

●GRBS 12th hrly








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