GENERAL MEDICINE 4
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Anti HCV :
29/10/21
ECG:
DIAGNOSIS : CKD
A 85 yr old male patient from nakerekal labour by occupation came to OPD with cheif complaint of lower back pain ascites and loss of apatite since 20 days.
HISTORY OF PRESENT ILLNESS :
patient was asymptomatic 3 months back he used to go to labour work ( presently not working ) when he developed itching on hands later it subsided and he developed pedal edema
He visted to hospital and later used medication for pedal edema and edema subsided
Later he developed ascites in stomach 20 days back which is not subsided
Patient had loss of apatite after he developed ascites 20 days back
He visted and admitted in the hospital
PAST HISTORY ..
patient was a daily labour by work he used to getup in the morning and go to work by cycling.
Patient had a amputation of right leg thumb finger 20 yrs back
Patient had a eye surgery for right eye 4 yrs back as he developed blured vision
Now he develops blured vision for left eye which is not operated
Patient is partially deaf since 1 year
History of hyper tension since 3 months
History of SOB grade 4 since 3 months .
FAMILY HISTORY :
no relavant family history
PERSONAL HISTORY :
Diet : mixed
Apatite : loss of appatie
Sleep : normal
Bowel and bladder : normal
Addictions : occasionally alcoholic
TREATMENT HISTORY :
No allergy to known drugs .
GENERAL EXAMINATION:
Patient is concious coherent well built
Pallor is present
No cynosis
No icterus
No clubbing
Vitals :
Temp : 98⁰f
BP : 220/100mm/ hg
PULSE : 72 beats / min
RESPIRATORY RATE : 18 cycles /min
SYSTEMIC EXAMINATION :
CVS : s1 and s2 are heard, no murmmers
CNS : consicious, speech normal
Respiratory : dysponea is present ,no wheezing sounds,
Per abdomen:
Shape of abdomen : distended
No palpable mass
Fluid is present
Liver not palpable
Spleen not palpable
Investigations: :
22/10/21
CBP :
RFT :
ULTRA SOUND:
CUE:
25/10/21 :
Hbs Ag _ rapid :
Anti HCV :
29/10/21
SARS :
2/11/21 :
3/11/21
ECG:
DIAGNOSIS : CKD
TREATMENT :
2/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD
3/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD
5/11/21
Tab.nicardia 20mg BD
Tab.lasix 40mg BD
Tab.nodosis 300 mg BD
Inj.erythropoitin 400 iv weekly once
Tab .orofex BD .
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