A case of 56 year old male with chronic kidney failure
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FINAL EXAM SHORT CASE :
A 56 yr old male patient resident of Aganmothkur,who is a farmer ,came to the hospital with chief complaints of shortness of breath since 1 day.
Patient was apparently asymptomatic 3 months back.Then he developed bilateral pedal edema of grade-4 pitting type and shortness of breath grade-3 for which he was hospitalised and was diagnosed to have Chronic kidney disease .Since then he had 11 sessions of hemodialysis .The last one was done as he had shortness of breath of grade-3 and bilateral pedal odema grade -3 pitting type .
Past history:He went to hospital as he had fever and was diagnosed to have Hypertension 5 months back .
Underwent surgery for intestinal perforation 2 yrs ago.
GENERAL EXAMINATION: The patient is conscious, coherent, coperative .Moderately built and nourished.
Pallor present
Icterus present.
Bilateral pedal odema -pitting type-grade 3
No cyanosis, No clubbing, No koilonychia,No lymphadenopathy.
Incisional hernia above the umbilicus
Patient is afebrile
Pulse : 90 beats/min
Respiratory rate : 20 cycles / min
BP : 140/90 mm hg
CNS examination:
Higher mental functions-normal
Cranial nerves- intact
Sensory system- normal
Motor system- normal
Meningeal signs- absent
Cerebellar signs- absent
CARDIOVASCULAR SYSTEM
Apex beat: 5th intercostal space lateral to midclavicular line
S1 and s2 heard
JVP normal
RESPIRATORY SYSTEM
Breath sounds: normal
No additional breath sounds
☆Management:
Hemodialysis:through Central Venous Catheter.
Drugs:
Tab.lasix 40mg bd
Tab.nicardia 10mg tid
Tab.Arkamin 0.1mg tid
Tab.shelcal 500 mg od
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