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This is a case of 38 year old male patient a daily labour by occupation presented to opd with chief complaint of decreased appatite from past four months and fever since three months,it's raised since ten days, decreased urine output, nausea.
History of present illness :
Patient was asymptomatic five months back then he developed loss of appetite , reduced sleep and decreased urine output associated with fever.
No h/o Sob
No h/o facial puffiness
No h/o chest pain
No h/o palpitations
Patient is undergoing hemodialysis (2 times)
Past history:
There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy,no h/o any surgeries.
Personal history:
Diet: mixed.
Sleep : reduced
Bowel and bladder movements :Normal.
Appatite:loss of appetite
Micturition: decreased
Habits: Alcoholic and smoker.
Drug history:
There is no history of allergies to any known drugs.
Family history:
There is no history of similar complaints in family members.
General Examination:
The patient is conscious, coherant and cooperative. He is well oriented to time , place and person . Moderately built and nourished
Anemia present
Pallor present
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy.
Vitals
PR 90bpm
RR 17cpm
BP 110/70mmHg
SpO2 98% in room air
Temperature febrile.
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Inspection:
Chest wall is bilaterally symmetrical
No Precordial bulge
No visible pulsations, engorged veins,scars, sinuses
Palpation:
JVP - normal
Apex beat : felt in the left 5th intercostal space
In midclavicular line
Ausculation:
S1 ,S2 Heard
RESPIRATORY SYSTEM
Bilateral airway +
Position of trachea- central
Normal vesicular breath sounds - heard
No added sounds
PER ABDOMEN
Abdomen is soft and non tender
Bowel sounds heard
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM
Patient is conscious
Reflexes are normal
Speech is normal.
Investigations:
Provisional diagnosis:
Acute kidney injury on CKD
Treatment plan:
Inj :Lasix 40 mg IV -OD
Tab Nudosis 500mg oral -OD
Tab Shelcal oral-OD
Tab Orofer XT oral -BD
Inj Erythropoietin 4000 IV
Inj Iron sucrose
Syrup Artstozyme 10 ml oral -TID.
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