GENERAL MEDICINE  CASE-4

sept14th, 2021

''This is the online E log book to discuss our patients de-identified health data shared after taking his/her/guardian's signed informed consent. Here ,we discuss our individual patient's problem throught series of inputs from available globel online community of experts with an aim to slove those patients clinical problems with collective current best evidence based inputs.'

A60yrs male patient presented to opd with chief complaints of shortness of breath, decresed urine output along with generalised weakness since 1year.

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 1yr back and developed pedal edema along with shortness of breath and decresed urine output.

Then he visited our hospital and was admitted into dialysis ward because on  diagnosis he as chronic kidney disease. He was on dialysis since 1month once in 3days. after dialysis patient complains of abdominal pain ,chest pain along with fever.

PAST HISTORY

patient with history of hypertenion since 10years.
And also  on medication for acidity problems sice 10 yrs.

FAMILY HISTORY
 
No similar complaints in family.

PERSONAL HISTORY
 
Appetite-normal
Diet-mixed
Bowel and bladder movements-normal
Sleep-adequent
Habits-alcohol and smoking

GENERAL EXAMINATION

Patient was coherent ,conscious,cooperative
No pallor
No cyanosis
No clubbing
No lymphadenopathy 

VITALS:
Temp-normal
PR-90/min
RR-22 cpm
BP-140/90 mmHg
SPO2-98% at room air

SYSTEMIC EXAMINATION 

 CVS:S1 S2 heard
RESPIRATORY:Bronchial artery embolism
                            Normal breath sound is heard
PER ABDOMEN: Scaphoid,no tenderness
CNS:No focal neurological deficits

PROVISIONAL DIADNOSIS

Chronic Kidney Diseases

INVESTIGATIONS

Blood urea-127mg/dl
Serum creatinine-8.3mg/dl
Serum electrolytes
       Na-132mEq/L
       K-4.6mEq/L
       Cl-99mEq/L
Serum IRON-100ug/dl

COMPLETE BLOOD PICTURE

Haemoglobin-8.8gm/dl
Total count-5,900cells/cumm
Platelet count-3.16L/cu.mm

ECG



TREATMENT

TAB.NICARDIA 20mg po/BD
TAB.IASIX 40mg PO/BD
TAB.NODOSIS 500mg PO/BD
TAB.OROFER XT PO/BD
TAB.SHELCAL 500mg PO/OD
FLUID RESTRICTION[<1.5 lit]
SALT RESTRICTION [<4 gm]
Syp.ASCORIL 10ml PO/BD




   


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