51 year old with chronic kidney disease on mhd

 51 year old male came with complains of ulcer on left foot and right foot since 3 months. 

Ulcer was insidious in onset and gradually progressive( initally a blister progressed to present size) non healing type. 

He was a k/c/o diabetes and hypertension since 30 years for which he was taking medication. 

He had a history of difficulty in micturition 10 years back for which he went to hospital and diagnosed with CKD and was on medication. 

4 months back he developed bilateral pedal edema and started dialysis ( maintenance hemodialysis). 20 dialysis were done in kims, narketpally and 10 dialysis were done in suryapet. 

He has habbit of drinking since 35 years( 90ml- quarter/ day) . 

Not a k/c/o asthma, tuberculosis, vascular and cardiac disorders. 

No past history of similar complaints

No past history of hospitilization or surgery

FAMILY HISTORY:

No H/O Diabetes, Hypertension, Asthma, Epilepsy, Tuberculosis, CVA, CAD. 

PERSONAL HISTORY:

Diet :mixed

Sleep :adequate 

Bowel and bladder :regular

Appetite: normal

Micturition :normal

GENERAL EXAMINATION: 

Patient is conscious coherent and cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy

Pedal edema present

VITALS:

Temperature:99 F

Pulse:82bpm

Blood pressure:150/90mm of hg

Respiratory rate:26 cpm

SpO2 :96%at room air

SYSTEMIC EXAMINATION:

CVS EXAMINATION:

s1,s2 heard

No murmurs

RESPIRATORY SYSTEM EXAMINATION :

Bilateral air entry present

Normal vesicular breath sounds heard

No added sounds heard

PER ABDOMEN EXAMINATION:

Scaphoid abdomen

No tenderness

No palpable mass 

Bowel sounds heard. 

Liver and spleen not palpable. 

CNS EXAMINATION:

No abnormality detected. 


PROVISIONAL DIAGNOSIS:

51 YEAR OLD MALE WITH CHRONIC KIDNEY DISEASE ON MAINTENANCE HEMODIALYSIS.

Treatment:

TAB. LASIX 40 MG BD

TAB. NICARDIA 10 MG STAT SOS

TAB. NODOSIS

IRON SUCROSE WEEKLY TWICE

ERYTHROPOIETIN WEEKLY ONCE

TAB PANTOP 40 MG OD

TAB MVT OD. 



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