CKD

A 65yr old male patient who is a resident of nakrekal and farmer by occupation came to the OPD with the chief complaints of
 
Urinary retention since 2 days
Abdominal distention since 2 days
Fever since 3 days
HISTORY OF PRESENT ILLNESS:

PAST HISTORY
He had right sided indirect inguinal hernia for which hernioraphy was done 13 years back.

He is known case hypertension since 4 years and he is on medication since 4 years
No history of diabetes,asthma,tb,cad,stroke 
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:urinary retention
Addictions:regular alcoholic
FAMILY HISTORY:
family member has hypertension 
No history of diabetes,asthma,tb,cad,stroke.
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:82b/m
Respiratory rate:22c/m
BP:140/70mmhg
Spo2:99
Grbs:134mg%

Pallor: present
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:present
SYSTEMIC EXAMINATION:
Shape:scaphoid
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
 No Tenderness
No local rise of temperature
DEEP PALPATION:
liver:not palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
Liver span:14cm
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CARDIOVASCULAR SYSTEM:
S1,S2 Heard
 no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact

Investigations






Clinical images


Provisional diagnosis: CKD

TREATMENT: 

TAB LASIX  - 400 Mg bd

Tab nodosis-500mg bd

Inj metrogel-500mg tid

Tab pan- 40mg OD

Oroferxt- OD

Tab shelcal-od

Tab nicardipine-20mg bd

Syp arystozyme-15ml bd







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