Fever unclassified 55/M 202410905

 Admission Date: 07/03/2024 01:00 PM



Discharge Date

Date:21/04/2024


Discharge Type: Relieved


Diagnosis

CKD ON MHD

Case History and Clinical Findings

C/O PEDAL EDEMA SINCE 1 WEEK

C/O DECREASED URINE OUTPUT SINCE 1 WEEK

PT WAS APPARENTLY ASYMPTOMATIC 1 WEEK AGO THEN HE DEVELOPED PEDALEDEMA SINCE 1WEEK , WHICH WAS INSIDIOUS IN ONSET AND GRADUALLY PROGRESIVE IN NATURE

ALSO C/O DECREASED URINE OUTPUT SINCE 1 WEEK

N/K/C/O HTN , CVA , CAD , ASTHMA

O/E:

NO PALLOR ICTERUS CYANOSIS CLUBBING AND GENERALIZED LYMPHADENOPATHY

PEDAL EDEMA PRESENT

TEMPERATURE 97.8

PR- 79BPM

RR-18CPM

BP- 140/90

GRBS 112

SPO2- 98% AT RA

CVS- SI S2HEARD NO THRILLS AND MURMURS


RS- B/LAE NVBS HEARD

P/A- SOFT AND NON TENDER NO PALPABLE MASS

CNS - NFND

CRANIAL NERVES INTACT

SENSORY AND MOTOR SYSTEM NORMAL

Investigation

LIVER FUNCTION TEST (LFT) 06-03-2024 12:55:PM Total Bilurubin0.77 mg/dlDirect Bilurubin0.20 mg/dlSGOT(AST)10 IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATASE473 IU/LTOTAL PROTEINS7.4 gm/dlALBUMIN3.68 gm/dlA/G RATIO0.99RFT 06-03-2024 12:55:PM UREA47 mg/dlCREATININE3.4 mg/dlURIC ACID3.7 mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS2.9 mg/dlSODIUM137 mmol/LPOTASSIUM3.7 mmol/L.CHLORIDE102 mmol/LAnti HCV Antibodies - RAPID06-03-2024 12:55:PMNon Reactive HBsAg-RAPID06-03-2024 12:55:PMNegative

USG REPORT :

IMPRESSION :

RIGHT KIDNEY SHOWS GRADE 3 RPD CHANGES AND DECREASED SIZE

LEFT KIDNEY SHOWS GRADE 3 RPD CHANGES

HEMOGRAM : 7/3/24

HB - 7.7

TLC - 20,000

PCV - 22.6

PLT - 1.75 LAKHS / CU MM

Treatment Given(Enter only Generic Name)

T.NODOSIS 500 MG PO BD

T.LASIX 40 MG PO / BD

T.OROFER XT PO/OD

T.SHELCAL -CT PO OD

CAP BIO D3 PO / ONCE WEEKLY

T.NICARDIPINE 20 MG PO / TID

Advice at Discharge

FLUID RESTRICTION <1.5 L / DAY

SALT RESTRICTION <2 G / DAY

T.NODOSIS 500 MG PO BD


T.LASIX 40 MG PO / BD

T.OROFER XT PO/OD

T.SHELCAL -CT PO OD

CAP BIO D3 PO / ONCE WEEKLY

T.NICARDIPINE 20 MG PO / TID






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