Case history

 Date of admission : 06-09-2021


A 28 yr old male Patient of miryalaguda, came to our hospital with complaints of weakness and decreased urine output and got diagnosed as AKI

HISTORY OF PRESENT ILLNESS:

-Patient was asymptomatic till April

-Patient had a history of weight loss since 1& 1/2 month 

-Patient has decreased appetite and generalized itching 

-Patient had undergone hemodialysis 4 times 

HISTORY OF PAST ILLNESS:

-Patient has no history of pedal edema and SOB

-No history of diabetes 

-No history of hypertension 

PERSONAL HISTORY :

-Normal Appetite 

-Bowel regular 

-Micturition -Normal 

-Patient was occasional alcoholic and non-smoker 

FAMILY HISTORY:

-No history of diabetes 

-No history of hypertension 

-No history of cancer 

GENERAL EXAMINATION:

-Patient is conscious, coherent and cooperative 

- No signs of cyanosis

-No signs of Lymphadenopathy 

-No signs of Clubbing 

-No signs of interest

VITALS:

Temperature-afebrile 

Pulse rate-92bpm

Respiratory rate - normal 

SYSTEMIC EXAMINATION:

CVS-

- Thrills -No

-cardiac sounds - S1 and S2 heard 

RESPIRATORY SYSTEM'

-No dyspnea

- No wheezing 

-Position of trachea-central 

ABDOMEN:

-Distended,soft and non tender 

- Bowel sounds heard 

- Free fluid -No

CNS:

- Patient is conscious 

-speech normal 

Sensory and motor reflexes- intact

PROVISIONAL DIAGNOSIS:

CKD ON MHD 

INVESTIGATION:





TREATMENT:

T.LASIX 20 mg/PO/BD

T.NICARDIA RETARD 20mg/PO/BD

T.NODOSIS 500mg /PO/TID 

T.OROFER XT/PO/BD

T.SHELCAL 500mg /PO/OD

T.ALPHA D3 0.25mg /PO/OD

T.ERYTHROPOIETIN 4000 IU



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