BY JAVAD SHAHNOOSHI

• IPnumber :

• Admission Date:

• Discharge Date:

• Department/Unit: medicine.3

• Age: 62

• Sex : M

Chief Complains & H/O Present illness:

• Patient was normal 10 days back when he

developed fatiguality.it was insiduos in onset &

increase on walking.

• C/o breathlessness on exertion.

• Swelling of upper & lower limb since 10 days

Previous history:• H/o HTN since 5 yrs on T.betacard, T.Arkamine.• H/o surgery for gall bladder stone 2 yrs back.

Social History:

+ Diet: mixed

+ Sleep: decreased

+ Appetite: decreased

+ Bowel And Bladder: N

+ Habit: none

• Blood Pressure: 160/100 mmg/Hg

• Pulse Rate: 72 beat/min

• Temperature: Afebril• Pallor: +• Icterus: -• Cyanosis: -• Clubbing: -• Lymphadenopathy: -• Edema: +• Edema in both U& L limb& over hands• B/L pedal edema

˃ Respiratory system: : NVBS+, no added sound.

˃ CVS : S1S2 ,no murmur

˃ P/A :soft, non tender ,no organomegaly ,abdomen look

distended

˃ CNS: HMF (N) , motor & sensory system (N)

˃ USG of abdomen and pelvic showes Grade 3

nephropathy with multiple cyst.

˃ Fundus examination : Grade 1 HTN

Laboratory data:Test Normal value 13.4.11 15.4.11 17.4.11 18.4.11 23.4.11

HB g/dl 13-18 7.8 10.1

TC cell/cmm 4.5-11k 6.800

P 40-75 73

L 25-33 20

E 1-3 0.4

RBS mg/dl 80-140 76

S.ELECTROLYTE

NA mmol/it 135-145 137 137 131

K mmol/it 3.5-5 5.6 4.3 4.6

CL mmol/it 96-106 100 103 9.9

B.UREA mg/dl 15-40 146 58 63 102

SR.CREATININ mg/dl

0.9-1.5 7.9 4.2 5 4 5.9

ESR mm/hr 0-15 76

TEST NORMAL VALUE

15.7.11 18.7.11

urine examination

ALBUMIN _ +++

PC Nil 8-10

EP Trace 2-4

RBC _ 24

SERUM COLESTROL

134

HDL mg/dl 35-55 42

LDL mg/dl 85-150 84

TRIGLYCERID 60-170 58

PCV 47-54 29.3

˃ Based on the subjective and objective evidences the patient was diagnosed

to have hypetension , nephropathy and ESRD.

˃ Breathlessness is symptom of HTN &CRF.

˃ Pallor ( decrease HB ) due to disturbance of erythropoetin cycle(shortend

RBC survival ,marrow suppression by waste product).

˃ Edema due to retention of Na and H2O in CRF.

˃ increasing in level of urea & creatinin is due to CRF.

˃ Hyperkalemia is clinical manifestation of CRF.

˃ Proteinuria due to CRF.

Brand Name Generic NameDose &

FrequencyDate Begun

Date Ended

INJ LASIX iv Furosemid 40 mg 1-1-0 13.7.11 16.7.11

T.BETACARD_AM Atenolo 50mg+ amlodipine 5mg

1-0-1 13.7.11 24.7.11

T.ARKAMIN Clonidine 0.1mg 1-1-1 13.7.11 24.7.11

T .STATOR Atrovastatin 20mg 0-0-1 13.7.11 24.7.11

T. ECOSPRIN Asprin 75mg 0-1-0 13.7.11 24.7.11

T. PRAZOPRESS xl Prazosin 2.5mg 0-1-0 13.7.11 24.7.11

T. NEPHROCAP Vit c,B3 ,B6,folic acid,B2,B1,methyl cobalamine,Biotin

1-0-0 14.7.11 24.7.11

SHELCAL Ca carbonate+vit D3 0 -1-0 14.7.11 24.7.11

T.PHOSTAT Ca acetate 1-0-1 14.7.11 24.7.11

T.PROXYVON Paracetamol400mg+dextropropoxyphen 65mg

20.7.1121.7.1122.7.11

23.7.11

10Pack cell during dialysis

14.7.11 16.7.11 17.7.11

BP:150/100PR:82

BP:166/90PR:74

BP:142/80PR:80

18.7.11 19.7.11 20.7.11

BP:140/84PR:64

BP:124/70PR:62

BP:120/70PR:68

21.7.11 22.7.11 23.7.11

BP:110/70PR:70

BP: 110/80PR:70

BP:142/80PR:70

24.7.11

BP:110/80PR: 68

Patient Progress Report

Brand name Generic name Dose & frequency

T betacard Atenolol+amlodipine 40mg 1-1-0

T. Arkamin Clonidine 0.1mg 1-1-1

T stator Atrovastatin 20mg 0-0-1

T.Ecosprine Asprin 75mg 0-1-0

T. Prazopress Prazosin 2.5mg 0-1-0

T.Phostal

T.Shelkal Ca carbonate + vit D

500mg 1-0-1

T.nephrocap Multi vit 1-0-0

Suggestion to the physician :• Urine culture test should be done to

confirm the infection.• Clonidine & prazosine better avoided

due to the the possible ADR.• Low dose of thiazide ,chlorthalidone+ B

blocker is suitable.• Aspirin is CI to pt to sever renal

impairment ,instead he can use clopidogrel.

• Drug of pantoprazol should suggest.

» Dietary modification :intake of dietary protein(20 gm daily), pottasium containing food & fruit should be restricted.

» Water intake should be adjusted.» Eat meals that are low in fat and cholesterol» Get regular exercise (talk to your doctor or nurse

before starting).» Patient have to restrict salt, potassium, phosphorous,

and other electrolytes.