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Name: Kattekola Sathwik
Roll no 58
2017 batch
A 35 yr old male driver has come to the OPD with following presentation...
About 4 yr ago he developed lower back ache insidious in onset. As it was not controllable with the medications he went to a hospital and got his tests done. R FT was deranged and 2 sessions of hemodialysis were done..
About 4 months ago he presented to casualty with the complaints of grade 4 shortness of Breath, no history of chest pain, palpitations, no history of expectoration, cough
He also had a history of decreased urine output. No history of urgency, frequency, burning micturition.
He was diagnosed as chronic Renal failure and was put on Haemodialysis (5 cycles)
Now he has come for Haemodialysis about 4 days ago
Pedal edema upto level of ankle was relieved on hemodialysis.
He is having a cough without expectoration since about 2 days.
Past history
He is a known hypertensive since 4 months and is on regular medication. He is compliant to medication.
Personal history
He was an occasional alcoholic until about 4 years ago.
Appetite is good
Diet is mixed
Bowel habits are regular
Sleep is adequate
Family history
No similar complaints in the family
General physical examination
The patient is conscious coherent cooperative
He is well oriented to time place and person
Moderately buit and nourished
Speech is good
Gait : normal
Vitals
(At the presentation)
-He is afebrile
-Pulse
- Rate : 82 beats per minute
- Rhythm: regular
- Character : normal
- Volume : normal
- Condition of vessel wall : soft
- No radio radial delay
Respiratory rate: 24 cycles/minute
Blood pressure :130/70 mmHg
Systemic examination
Respiratory system
The chest is elliptical
Moving equally on both sides with respiration
Apex beat seen and felt at 5 th intercostal space 1 cm to medial to mid-clavicular line
Bilateral air entry present
Trachea is central
Resonant note on percussion over the chest
Normal vesicular breath sounds were Heard.
Cardiovascular system
The chest is elliptical
Moving equally on both sides with respiration
Apex beat seen and felt at 5 th intercostal space 1 cm medial to mid-clavicular line
Heart borders in normal limits
On auscultation, S1 S2 were heard
Per abdomen: soft, bowel sounds heard.
Investigations
Haemoglobin: 6g%
Blood urea :152
Serum creatinine: 11.4
SOAP NOTES
Diagnosis : Chronic kidney disease on Haemodialysis
Patient has come for dialysis
Treatment
Tab . LASIX 40 MG ×BD
Tab. NICARDIA 10 MG PER ORAL BD
Tab. CLONIDINE 0.1 mg BD PERORAL
Tab. BIO-DG 0.25 mcg peroral OD
Tab. Orofer -XT peroral BD
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