Prefinal case history

 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. 

A 50 year old male patient came to the opd with chief complaints of shortness of breath,decreased urine output,nausea,bipedal edema and constipation since 20 days.

History of present illness :

- Patient was apparently asymptomatic 15 years back then  he developed fever, shortness of breath,decreased urine output,constipation and was brought to the opd and had underwent dialysis but the symptoms didn’t subside so he was taken to Hyderabad. There he was told he had polycystic kidney disease which can be cured on medication. 

Patient had fallen down and had a iliac bone fracture for which he underwent a surgery during which he was diagnosed with hypertension 10 months back.

Patient has developed same symptoms again and came to the opd.

History of past illness : 

- The patient is a known case of hypertension since 10 months and is on medication.

- He is not a known case of diabetes, epilepsy, tuberculosis, asthma.

Personal history : 

- The patient has loss of appetite since 10 days

- he takes mixed diet

- he has proper bowel and bladder movements

- he has constipation

-no sleep disturbances 

- patient is an occasional alcohol consumer and smoker 

Family history :

- There are no similar complaints in the family members

Treatment history :

- he is not a known case of any drug allergy

General examination :

- Patient is conscious, coherent, cooperative at the time of joining

- Pallor is present

- No icterus

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- pedal edema js present which is of pitting type




Vitals : temperature - 98.5 F

              Pulse rate - 112bpm

              Respiratory rate - 18 cycles per minute

              BP - 110/90 mm Hg

              Spo2-99%

Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetrical

- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard


RESPIRATORY SYSTEM

- Position of trachea is central 

- Bilateral air entry us normal

- Normal vesicular breath sounds heard

- No added sounds


PER ABDOMEN 

- abdomen is not tender

- bowel sounds heard 

-no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal

Investigations :












Diagnosis : Chronic kidney disease with hyponatremia 

Treatment :

Fluid restriction<1L/day

Salt restriction <2.4g/day

Tab lasix 40mg po/TID

Tab NICARDIA 20mg po/BD 

Tab orofer xt po/OD 

Tab NODOSIS 550mg po/BD 

Tab shelcal 500mg po/OD 

Inj erythropoietin 4000IV Weekly once

Inj Iron sucrose 1amp in 100 ml NS IV/during dialysis 


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