a patient with ckd on mhd
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A 45 yr old female patient was presented to OPD with chief complaint of reduced urine output and shortness of breathing from 3days
History of present illness:
Patient had fever 10 days back with no chills and subsided on medication
She had 3 episodes of vomittings 2days back
Then she developed facial puffiness and pedal edema along with decreased urinary output 1week back
History of past :-
H/o undergoing heamodialysis of 3sessions 1year back
No H/o DM and HTN
PERSONAL HISTORY
Married
Occupation: housewife
Appetite:normal
Diet:mixed
Bowel and bladder:regular
No known allergies
Alcohol history : no consumption of alcohol
FAMILY HISTORY
Not significant
General examination:
Patient is c/c/c
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Vitals:
Afebrile
Pluse rate : 92/min
Respiratory rate : 22/ min
Bp: 150/90 mm hg
PR: 95 bpm
RR: 22 cpm
SpO2: 99%
CVS: S1,S2 +
RS: BAE+
P/A: SOFT, NON TENDER
CKD on mhd
C/O reduced urine output
C/ O sob grade 4
C/o easy fatiguability.
Vitals at admission :-
Bp: 160/90 mm hg
PR: 99 bpm
RR: 22 cpm
SpO2: 99%
CVS: S1,S2 +
RS: BAE+
P/A: SOFT, NON TENDER.
Treatment and follow up :-
1. Fluid upto 2 liters
2. Salt restriction <4gm / day
3. Inj PIPTAZ 4.5 gm/ IV /STAT
4. METROGYL 500 mg (100m IV/RA)
5. TAB NONOSIS 500 mg/po / bd
6. TAB SM6LCAL CT PO/OD
7. TAB OROFER XT PO/ BD
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