65 year male with CKD

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Complaints: 

1) Shortness of breath since 15 days 

2) Decreased urine output since 15 days 

3) cough with sputum since 4-5 days 

4) Low back ache since 1 year .

History of present illness : 

Patient is shepherd by occupation and also used to do farming and apparently asymptomatic 10 years ago and then developed diminished vision in the right eye ,where he was diagnosed with cataract and got operated.

10 years back, post surgery ,patient stopped smoking and alcohol intake in view of rituals to lord Shiva

Since 10 years , after work ,Patient had Generalized body pains, went to RMP and used to take pain killers ,on/off 

1 year back ,patient developed low back ache for which he went to the hospital and patient had deranged renal parameters and started on conservative management.patient used it for 1 month and stopped.

1 month back patient had increased on routine visit to rmp and started on antihypertensive.

Since 15 days ,patient developed  Shortness of breath associated with decreased urine output and cough with sputum since 4-5 days and no history of fever.

He was started on hemodialysis on 17/12/22.

Past history:

Known CKD since 1 year

Known Hypertensive since 1 month.

PERSONAL HISTORY

Diet - Mixed 

Appetite - Decreased

Sleep - Inadequate 

Bladder - Decreased urine output 

Bowel movements - Regular 

Smoker and alcohol stopped 10 years back

FAMILY HISTORY

• Not significant 

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 

Well oriented to Time place person 

Thin build and moderately nourished 

• Pallor - absent 

• Icterus - Absent 

• Clubbing - Absent 

• Koilonychia - Absent 

• Lymphedenopathy - Absent 

• Pedal oedema - absent 

• JVP - Normal 

VITALS

• Temperature - 99°F 

• Pulse rate - 80bpm

• Respiratory rate - 20 cpm

• BP - 180/100 mmHg

• SPO2 - 98% on room air 

• GRBS - 146 mg/dl 

Diagnosis: Chronic kidney Disease secondary to nsaid abuse,with known case of Hypertension.

Hemodialysis initiated on 17/12/22.