Case history-01

Date of admission:5-8-2021

A 50-year-old man presented to the OPD with chief complaints of SOB,decreased urine output and chest pain for the past 7 days.

•HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 10 years back, and then was diagnosed with Diabetes mellitus type2 and was started on Tab.GLIMI M2 OD.
 
4 years back he complained of hypertension and was using anti-hypertensive drugs.

5 days back patient presented to the casualty with pedal Edema,facial puffiness, abdominal distension on and off and diagnosed with CKD,DIABETES NEPHROPATHY.

From past 5 days he complains of constipation and has not passed stools and decreased urinary output since 5 days.

He also complains of altered sleep patterns from past 5 days.
 
•HISTORY OF PAST ILLNESS 
 Not a known case of CAD,Asthma,TB,Epilepsy,thyroid disorders.
There was a BGM operation in past 5 years due to water retention.
•PERSONAL HISTORY 
No history of consuming alcohol and smoking.
Decrease appetite 
Micturation-abnormal
Sleep- inadequate 
•FAMILY HISTORY
No similar complaints in the family 
No history of CVA,CAD,Asthma and thyroid disorder in the family.
•GENERAL EXAMINATION 
Patient is conscious,coherent and cooperative.
There is pedal edema
No cyanosis,clubbing,lymphadenopathy 
•VITALS
Temperature-a febrile 
Pulse rate-98bpm
Respiratory rate -8cpm
BP-16/100mmHg
Spo2 at room air-98%
•SYSTEMIC EXAMINATION 
cardiovascular system:
Thrills-No
Cardiac sounds-s1&s2 heard
Respiratory system:
Dyspnea-present 
No wheezing 
Position of trachea -central
Bilateral air entry- +
Normal vesicular breath sounds-heard
Central nervous system:
Patient is conscious 
Speech -normal
No signs of meningeal irritation
Sensory and motor reflexs-intact 
•PROVISIONAL DIAGNOSIS 
Chronic kidney disease on maintanance hemodialysis
•INVESTIGATION 
RFT
urea-94mg/dl 
Creatinine-3.9mg/dl 
Uric acid-6.9mg/dl
Calcium-9.6mg/dl
Phosphorus-4.3mg/dl
Sodium-135mEq/L
Potassium-3.5mEq/L
Chloride-101mEq/L
•TREATMENT 
Inj. LASIX 40mg IV /BD
Tab. NICARDIA 10mgPO/TID
Tab. ORAFER-XT PO/BD
Inj.ERYTHROPOIETIN 4000IU S/C Once weekly 
Tab. SHELCAL 500mg PO/OD
Tab. NODOSIS 550mg PO/BD
Fluid restriction up to 1L per a day
Salt restriction less than 2 gms per a day 


Comments

Post a Comment

Popular posts from this blog

Final exam

Image
  This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs A 67 yr old male patient presented to the opd with the chief complaints of shortness of breath since 2-3 days, bilateral pedal edema since 3 days, orthopnea,PND History of present illness: patient was apparently normal 20 yrs Back then he developed severe cough with sputum and also shortness of breath.then he was diagnosed with TB.he used ATT course for 9 months and relieved. Now patient again developed shortness of breath of grade 2-3, grade-2 pedal edema of pitting type. Past history: known case of TB. Not a known case of diabetes, hypertension, asthama , epilepsy. Personal history: patient follow
Read more

Case history-04

Image
  This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  40 year old male farmer by occupation was brought to opd with chief complaints of weakness of b/l lower limbs and upper limbs since 4 days Unable to walk since 2 days.  HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 4 days back and then while he was dancing in Ganesh nimarjanum he suddenly fell down due to weakness of B/L lower limbs which was sudden in onset, progressive in nature ( initially walked with support, now can't move.)  weakness now progressed to B/L upper limbs.  No h/o loss if sensations No h/o headache, giddiness, slurred speech, deviation of mouth or involuntary moveme
Read more

Case history-02

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. A 30 year old female came to the casualty with the chief complaints of cough since 20 days and SOB since 3-4 days.Patient a/a 20 days back.Then she developed cough which is insidious in onset and intermittent and associated with expectoration which is whitish in colour and scanty in amount.It is associated with right sided chest pain which is sharp pricking  type of pain and increased on inspiration.It is also associated with fever since 20 days.Low grade, intermittent fever subsided on taking medications. HISTORY OF PRESENT ILLNESS:- SOB since 3-4 days which is insidious in onset and non-progressive
Read more