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 A 42 year old male , resident of Choutupal Who is daily wage labourer by occupation came to opd for regular dialysis.


History of presenting illness:


Patient was apparantly asymptomatic 1 .5yr back 

Then after taking covid vaccination he developed fever

Fever was present through out the day 

Not associated with vomitings,nausea,burning micturition .

Generalised weakness was present 

Didnt relieve on taking medication also 

So he visited our hospital.

Then he was diagnosed with hypertension and renal cyst. For which he was given medication.

 

After 6 months he developed shortness of breath and pedal edema upto ankle for a week. Then they visited Gandhi hospital 

Where dialysis was done for him and was admitted in hospital for nearly 20 days 

And then medication was given.

 

2 months back he developed shortness of breath and generalised weakness again 

Now he visited our hospital. His hemoglobin levels are low so blood transfusion of 4 units was done .since then he was on regular dialysis which is twice in a week.


15 days back after dialysis was done 

He developed watering eye in the right eye,peri orbital swelling was developed,tenderness was present,no eryyhema 

And then gradually vision was lost in that eye with in 5 days. 


After 7 days he noticed nasal bleeding from right nostril. He also develped an ulcer like

Wound on his right dorsum of nose.He also developed a swelling on the head on right side for which he was treated with fudic ointment.


Past history 

 

Known case of hypertension since 1 year and on medication 

Initially 1 year back he used to take 1 tablet /day now he is using 3 tablets / day


Not a known case of diabetes,TB,asthma 


Personal history 


Mixed diet

Appetite is reduced 

Normal bowel and bladder movements 

Sleep is adequate 


Addictions

 

Chronic alcoholic

Daily consumption of alcohol around 250 mL for around 20-25 yrs and stopped 1 1/2 yr back


Daily routine 


Before 

He used to wake up at 5:00am and does some house hold works and goes to work at 8:00 am after having breakfast and returns home at 3:00 pm for lunch and goes back to work and again returns home back between 8-9pm and will have dinner and sleep


Now 

 

He wakes up around 7:00 am and after taking shower will have breakfast by 8:00 am and then sleeps again and wakes up at 2:00 pm for lunch takes his medications and sleeps again and wakes up again at 8 pm will have dinner and sleeps again.


Family history: 

Not significant 




General examination 


Patient was conscious ,coherent and well oriented to time and place.

Patient was moderately built and nourished 


Vitals

BP 140 /90 mm of Hg

Pulse 80beats /min

Temperature afebrile

Respiratory rate  16 cycles/min


Pallor is present 

No icterus,cyanosis,clubbing,lymphadenopathy 










Local examination 


Eye: 


Right eye 


Mild swelling of upper lid is present 

Loss of vision is present

There Is no counting fingers ,perception of light 

Ocular movements are limited in all

Directions 

Light reflex is absent 

On palpation mild tenderness is seen 


Nose 

Epistaxis from right nostril 

Mild tenderness is present in maxillary region.

Ulcer like wound is present om the right dorsum of nose.



Head: 

 Single follicular cyst was seen on right side in frontal region 

Which was relieving with medication



Systemic examination:


CVS- S1 S2 heard no murmurs

CNS- No focal neurological deficit

RS- Normal vesicular sounds heard



Provisional diagnosis:

Chronic kidney disease 

Investigations:











Treatment
15 o6 23

Fluid restriction <2L /day
Salt restriction<2g/day
Tab Nicardin 10mg po /Bd
Tab shelcal 500mg po/Bd
Tab Nodosm 500mg po/Bd
Tab Oroferxpo po/oD
Tab bioD3 weekly once
Inj Angmatin 600mg iv/TLD
Inj.clindamycin 600mgiv/TLD

Fluid restriction <2L /day
Salt restriction<2g/day
Tab Nicardin 10mg po /Bd
Tab shelcal 500mg po/Bd
Tab Nodosm 500mg po/Bd
Tab Oroferxpo po/oD
Tab bioD3 weekly once


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