General medicine case-3

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Date of admission:12-09-21

A 70 year old female came with a chief complaint of pain in the stomach since 15 days.

History of present illness:

The patient was apparently asymptomatic 2 months back then developed shortness of breath. And pain in the stomach since 15 days.

She also experienced 4-5 episodes of loose stools 3 days back which then subsided.

4 days back the patient had high grade fever which subsided.

The patient is currently undergoing dialysis since 1 week.

History of past illness:

The patient is a known case of hypertension since 20 years and is on medication.

She is not a known case of diabetes, epilepsy, tuberculosis, asthma.

The patient underwent hysterectomy 4 years back.

Personal history:

The patient has normal appetite.

Has mixed diet.

Has adequate sleep.

Bowel movements are normal.

Decreased urine output since 3 days.

The patient has a habit of chewing betel leaf.

Family history:

There are no similar complaints in the family.

Treatment history: 

The patient is not allergic to any known drugs.

General examination:

Patient is conscious, coherent, cooperative at the time of joining.

- Pallor is present.

- No icterus present 

- No cyanosis present.

- No clubbing of fingers and toes.

- No lymphadenopathy.

-No pedal edema.

Vitals: 

Temperature: afebrile.

Pulse rate: 98 bpm.

Respiratory rate: 22 cycles per min.

BP: 120/90 mm/Hg

Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetric

- No precordial bulge

- No visible pulsations, engorged veins, scars, sinus

Palpation - JVP is normal

Auscultation - S1 and S2 heard.

RESPIRATORY SYSTEM

- Position of trachea is central

- Bilateral air entry us normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN

- abdomen is tender

- bowel sounds heard

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal.

Investigations:

Diagnosis:

Chronic kidney disease

Treatment:

1) Inj. CEFTRIAXONE 1mg/IV/BD

2) Inj. LASIX 40 mg IV/BD

3) Inj. ZOFER 4mg IV/SOS

 4) Inj. NODOSIS 500 mg PO/BD

5) TAB SHELLAL CT PO/OD

6) TAB LIVOGEN PO/BD

7) TAB MEXTL 50 mg PO/OD

 8) TAB ECOSPRIN-AV PO/OD/HS

9) Inj. ERYTHROPOIETIN 4000 IU/SC weekly

1) What other complications does hypertensive patients with CKD may have?

2) Do habits such as betel leaf chewing affect kidney function?