A 75 YEAR OLD MALE PATIENT WITH CHRONIC KIDNEY DISEASE ( CKD)
Date of admission: 01.07.2021
CHIEF COMPLAINTS:
On 1.7.21
A 75 year old male came to OPD with the chief complaints of:
• Itching all over the body since 15 days
•Shortness of breath (grade III) since 10 days (dyspnoea on exertion)
• Pedal edema (pitting type) - which was present since 1 year but aggravated in the past 10 days
HISTORY OF PRESENT ILLNESS:
• The patient was apparently asymptomatic 1 year ago and then developed pedal edema (pitting type, intermittent and gradual in onset) and has been on conservative treatment since then. Aggravated with alcohol or smoking.
•He was also diagnosed with hypertension a year back and was on medication.
• Since the past 1 year, he complained of shortness of breath, which aggravated in the past 10 days. It affected patient's daily routine, relieves on rest, medication and sitting position. Aggravated during night time in sleep, he wakes up gasping for air, positional variation, where in supine posture aggravation is seen, also aggravated when patient smokes. Associated with cough and mucoid sputum.
• He complains of itching all over his body since the last 15 days.
• He has no h/o fever and no h/o decreased urine output and burning micturition, no h/o altered sleep cycles, no h/o of chest pain and palpitations.
HISTORY OF PAST ILLNESS:
The patient was a known case of :
• Scrotal swelling since past 20 years.
• UCD since the past one year and also had been on conservative treatment.
• Hypertension since 1 year
• He sometimes complained of burning micturition .
• Not a k/c/O of DM, asthma, tuberculosis, stroke, CAD.
DRUG HISTORY:
• He has been on conservative drug treatment for pedal edema ( UCD) and hypertension for the past one year, but the name was not specified.
• No treatment history of Diabetes, CAD, asthma, tuberculosis, Antibiotics, hormones, Chemo radiation and blood transfusion.
PERSONAL HISTORY :
• No h/o of any altered sleep patterns.
• He follows a mixed diet and appetite is normal.
• Difficulty in passing stools since 1 month (only on alternate days).
• Normal micturition.
• He has been consuming alcohol occasionally (in a much diluted form) for the past 35-40 years,last drink was 2 months back.
• He has been smoking (chutta) for the past 35-40 years, the last smoke was 10 days back.
FAMILY HISTORY :
• No family history of hypertension, diabetes, heart diseases, kidney diseases, asthma, Tuberculosis and stroke.
GENERAL EXAMINATION:
• Pt. is conscious, coherent, cooperative
• Moderately built and moderately nourished.
• Pallor present
• No icterus and cyanosis
• No lymphadenopathy
• Mild dehydration is present
VITALS: ( on 01.07.2021)
1. Temperature - 103°F
2. Pulse rate - 90 bpm
3. BP - 140/70 mmHg
4. Respiratory rate - 18cpm
5. SPO2 at room air - 84 %
- 100 on 11lt
6. RBS - 101mg/dl
VITALS: (on 04.07.2021)
1. Temperature : 98.4°F
2. Pulse rate : 98
3. BP : 160/100 mmHg
4 Respiratory rate : 24
5. SPO2 at ra - 94%
SYSTEMIC EXAMINATION :
A. CARDIOVASCULAR SYSTEM
• S1 and S2 heard
• On auscultation, rt. Side cardiac rub +
• No thrills
• No cardiac murmurs
B. RESPIRATORY SYSTEM
• Wheezing sounds heard on auscultation of right lung.
• BAE +
• Normal Vesicular breath sounds present
• Trachea is central in position
• Dyspnea present
C. EXAMINATION OF THE ABDOMEN
• soft, non - tender
• No complaint of abdominal tightness
• No organomegaly
• Scaphoid shape of abdomen
• No tenderness, no palpable mass, no free fluid, no bruits
• Hernial orifices - normal
• Normal bowel sounds
D. CENTRAL NERVOUS SYSTEM
•Pt. is conscious, coherent and cooperative.
• Speech is normal.
•No neck stiffness and kerning's sign
Cranial nerves, motor system and sensory system are normal.
• No focal neurological deficit.
PROVISIONAL DIAGNOSIS :
? CHRONIC KIDNEY DISEASE WITH NEED FOR DIALYSIS.
? CHOLELITHIASIS
? UREMIC PRURITIS ( RENAL PRURITIS)
INVESTIGATIONS:
On 1.7.21:
A. BIOCHEMICAL INVESTIGATIONS:
1. Serum Creatinine
2 . Blood Urea
3.Random Blood Sugar
B. PATHOLOGICAL INVESTIGATIONS
1.Hemogram
C. ULTRASOUND REPORT:
D. MICROBIOLOGICAL EXAMINATION:
• HBsAg - Rapid test - negative
• HIV 1/2 Rapid test - negative
• Anti HCV antibodies - negative
• SARS CoV2 PCR test - negative
On 4.7.21:
A. ABG REPORT
B. HEMOGRAM :
C. LFT :
D. RFT :
E. BLOOD GROUPING and RH TYPE :
F. SERUM IRON :
On : 6.7.21 :
A . ABG :
B. HEMOGRAM :
C. RFT :
D. ECG :
TREATMENT :
On 1.7.21
• head end elevation to treat SOB and tachypnoea
• NTG 1gm 4ml - for cardiac rub
On 4.7.21
• salt ( <2g/day) and fluid (<1l/day) restriction
• Inj. Lasix
• Tab. Nodosis
• Tab Shelca
• Tab Oeofex
On cross consultation : ( 4.7.21)
DVL : UREMIC PRURITIS
• Moisturex soft lotion
• Liquid paraffin
• Atarax anti itch lotion
Adviced for serum transferring saturation
