Case history-7




 A 12 years old boy, studying 9 standard, from Nalgonda presented to opd 4 days back with cheif complaints of shortness of breathe and orthopnea.

History of past history: 

  Patient was apparently asymptotically 2 month back .he developed high grade fever and referred to local hospital 

Fever was subsided after 2 days.After one month he suffered with vomitings at night .

They is no incident of any blood in vomitings.

  He then immediately went to Hyderabad and found that his urea and creatinine levels are increased .

They immediately started dialysis .five sessions of dialysis have been done.

Patient suffered with chest pain only during sOB

No history of pedal edema,facial puffiness ,no decreased urine output 

 

Past history:

Hypertensive since 1 month 

No history of asthma,epilepsy, thyroid disorders

Patient was undergone 3 transfusions 1 month back 

Patient has increased sugar level which is subsided  1 week back


Family history:

No history of renal problem in family 


Allergic history:

No known case of drug allergy, 

Nt allergic to pollen ,dust 

Personal history:

Diet: mixed 

Sleep - normal 

Appetite-loss of appetite 

Bowel and bladder movement- normal


General examination:

Patient is conscious,coherent,co-operative

Pallor is present 

Absent of clubbing and cyanosis 

No lymphadenopathy 

No inflammation-no pedal edema

 

Vitals :

Temp -afebrile

Pulse rate-96bpm

Resp rate-24 cycles/ min

Bp-140 / 100 mm of hg

SpO2-86%in room temp 


Systemic examination:

Cvs-s1,s2 heard with no murmurs 

CNS- normal


Respiratory system:

Bilateral air entry is present 

No wheeze 

Investigation:












Provisional diagnosis:

Acute kidney disease 

IgA Nephropathy?

Treatment:

1. Tab lasix -40 mg po/bID

2. Tab zoffer-4 mg po/TID

3.tab .nodosis-500mg po/BID

4.oxygen inhalator for maintaining SpO2

5.tab orofer-AT po/bd

6.bp,pR,RR charting 

7.tab rantac-150 mg po/OID

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