23 year old male with left single kidney with generalised weakness

 

A 23year old male patient farmer by occupation came to casualty with c/o : generalised weakness since 1week.

HOPI : Patient was apparently asymptomatic 1week back, then he gradually developed generalised weakness.

PAST HISTORY : Patient is not a  k/c/o HTN,

 h/o DM, tb, epilepsy, cad, asthma.

-H/O Solitary left kidney only since birth.

Patient underwent 3 dialysis in the past.

PERSONAL HISTORY : Diet - mixed, Sleep - adequate, Appetite - normal, Bowel and bladder movements - normal.

GENERAL EXAMINATION : 

Patient is conscious, coherent, cooperative

well oriented to time and place.

No pallor, icterus, cyanosis, lymphadenopathy.

VITALS:

Temp- 98.6F

PR - 92bpm

Spo2 - 99%

RR - 16cpm

GRBS - 110mg/dl

Blood Pressure - 110/80mmhg

CVS - S1,S2+ no murmurs

RS - BAE+, nvbs heard

         no wheeze, no crepts

P/A - Soft, non tender, organomegaly

Bowel sounds +

CNS - NFND

INVESTIGATIONS

PROVISIONAL DIAGNOSIS :

Chronic renal failure with left single kidney.

TREATMENT :

1) FLUID AND SALT RESTRICTIOB

2)TAB NICARDIA 20MG PO/BD

3)TAB NODOSIS 500 PO/BD

4)TAB OROFER- XT PO/BD

5)CAP BIO- D3 PO/BD

6)INJ ERYTHROPOIETIN 5000 IU/SC/WEEKLY ONCE

7)TAB SHELCAL 500MG PO/BD.