General medicine case 5
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A 85 year old male labourer by occupation came to causality with chief complaints of lower back pain and swellings of legs .
History of present illness:
Patient was asymptomatic 3 months back then he had itching on hands and legs which was subsided . Later he developed pedal edema which was subsided on medication. 20 days back ,he developed ascites which was not subsided and patient also lost his appetite after he developed ascites .he visited and admitted in the hospital
Past history :
Patient was daily labourer by work he used to get up in the morning and go to work by cycling . Patient had a cataract surgery for right eye 4 years back as he developed blurred vision . Now he developed blured vision for left eye which is not operated . 20 years back he had amputation of right leg thumb finger. He is partially deaf since1 year. History of hypestension since 3 months. History of shortness of breath grade 4 since 3 months .
Personal history :
Diet : mixed
Sleep : Normal
Apetite : loss of apetite
Bowel and bladder movement : Normal
Addictions : occasionally alcoholic
Family history :
No similar history in the family
Treatment History :
No allergy to known drugs
General examination:
Patient is conscious and coherent and well built .
No cyanosis
No clubbing
No icterus
Pallor present
Investigations:
22/10 /21
25/10/21
2 /11 /21
Diagnosis :
CKD
Treatment:
2/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD
3/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD
5/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD .
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