Case of 50 yra old male with complaints of SOB since 10 days

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50 years Years old male came to OPD with cheif complaints of shortness of breath since 10 days.
Complaints of decreased urine output,nausea,B/L pedal edema and  constipation since 10 days.

Patient was aparently asymptomatic 15 years back, then developed B/L pedal edema , shortness of breath and was brought to our hospital 1 session of HD done.Patient was diagnosed with CKD 15 years back and was treated conservatively(on and off).

Now again 10 days back he came to OPD.

Past History :-

K/C/O HTN since 10 months and on regular medications.
Not a known case of DM , asthama , TB , Thyroid , epilepsy.

Personal History :-

Diet : mixed
Apetite : decreased since 10 days.
Sleep : adequate.
Bowel movements : irregular
Decreased urine output.

No any addictions.


On examination, patient is C/C/C .
Pallor present.
B/L pitting edema present till knees.





No cyanosis , icterus, clubbing , lymphadenopathy.
Temperature - 98.5*F
PR - 112/ min
RR - 18cpm
BP - 110/90 mmhg
Spo2 - 99% at RA
Grbs - 115 mg%

CVS :- S1 , S2 heard
RS - BAE present
P/A - soft and non tender
CNS - No focal Neurological deficet.


RFT :-
Serum Albumin :-
USG :-

Serology:-
Serology :-
Serology:-

CBP:-
CUE:-


Provisional diagnosis :-

Chronic kidney disease with Polycystic kidney disease and K/C/O HTN since 10 months.

18/12/21

Urea :- 219 mg/dl
Creatinine : 17.5 mg/dl
Hb : 5.2 gm%
 
1 session of HD was performed on 18th along with transfusion of 1 unit of PRBC.


19/12/21

Urea : 109 mg/dl
Creatinine : 11.3 mg/dl
Hb : 7.4 gm%

20 /12/21

Urea : 115 mg/dl
Creatinine : 11.2 mg/dl
Hb : 6.8 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.

21/12/21

Urea : 42 mg/dl
Creatinine : 4.9 mg/dl
Hb : 8.4 gm%
1 session of HD was done.

22/12/21

Urea : 36 mg/dl
Creatinine : 2.9 mg/dl
Hb : 9.1 gm%
1 session of HD was done along with transfusion of 1 unit of PRBC.

23/12/21

Hb : 9.8%

 

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