General medicine case discussion

 MEDICINE CASE DISCUSSION

This is 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 patients clinical problems with collective current best evidence based inputs This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome

Thursday, October 21, 2021

Vana Mounika, 3rd semester

Roll no : 140

CASE PRESENTATION :

A 58 yr old male patient labourer ( stone crusher) by occupation came to causality for dialysis

COMPLAINTS AND DURATION :

58 year male labourer (stone crusher) by occupation 

4 years back with c/o giddiness went to local hospital found out to be having high BP ( detected as HTN) and from then he was on medication.

2 years back with c/o bilateral pedal edema  came to hospital  diagonised as RENAL FAILURE and initiated dialysis weekly twice.

HISTORY OF PRESENT ILLNESS :

Now came for readmission

Now patient c/o Edema of the left upper limb ( since 4 months)

HISTORY OF PAST ILLNESS :

K/c/o HTN ( since 4 years)

On medication 

                   Tab NICARDIA 

                   Tab ARKAMINE

PERSONAL HISTORY  :

Married

Appetite - normal 

Sleep - adequate

Diet - mixed diet 

Bowels - regular

Micturition - normal 

FAMILY HISTORY :

not significant

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.

He is well oriented to time, place and person.

He is moderately built and well nourished.

VITALS :

Temp: 98.4 F

Pulse rate : 82 beats per minute

Blood pressure: 130/70 mm of Hg

Respiratory rate : 24 cycles per minute

SpO2 : 98% on room air

TREATMENT HISTORY :

on medication for HTN 

GENERAL EXAMINATION 

Pallor 

Icterus :No

Cyanosis :No

Clubbing of toes and fingers: No

Lymphadenopathy:No

Edema : present 






Malnutrition:No

Dehydration:No 

SYSTEMIC EXAMINATION :

A) CVS 

No thrills

Cardiac sounds S1 and S2 heard 

No cardiac murmers 

B) RESPIRATORY SYSTEM

No dysponea 

No wheezing

Position of trachea - center 

Breath sounds - vesicular

C) ABDOMEN 

Shape of abdomen - Scaphoid 

No tenderness

No palpable mass 

Hernial orifices - normal 

Free fluid - No 

Bruits - No

Liver - non palpable 

Spleen - non palpable 

Bowel sounds- heard

D) CNS 

Conscious and speech normal 

Motor and sensory system normal

PROVISIONAL DIAGNOSIS :

CKD on MHD 

with k/c/o HTN since 4 years 

Dialysis started in 2019

INVESTIGATIONS :






FINAL DIAGNOSIS :
  CKD on MHD

Treatment : 
                       
            1) fluid restriction < 1.5 lt/day
  
            2) Salt restriction   < 2 gm/day
             
            3) Tab. NICARDIA  10mg × po × TID
                                                (1-1-1)

            4) Tab. NODOSIS 500mg × po × BD
                                                ( 8 am- × -× )

            5) Tab . LASIX  40mg × po × 0D
                                         ( 8am-×-×)

            6) Tab. BIO- P3 0.25 × po × OD
                                            ×- 2pm- × 
     
            7) Inj. Erythropoietin 4000 IU
                          s/c weekly once
                              
 


 

 

 

 

 


















































 




























              








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