Case history-4
This is an online elog book to discuss our patients de-identified health data shared after taking his /her/ guardian informed consent here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
Date of admission: 4/11/21
36 yrs old male was apparently alright 4 yrs back, had low backache went to outside hospital and found out to be deranged RFT . 4 months back patient came to casualty with c/o grade IV, pedal edema, decreased urine output
HISTORY OF PRESENT ILLNESS:
diagnosed as chronic CRF , 5 sessions of haemodialysis later patient continued as MHD now came for re- admission
HISTORY OF PAST ILLNESS:
history of hypertension from 4 months
Diabetes mellitus from 2 yrs
On dialysis since 4 months
No tuberculosis
No asthama
No Lymphadenopathy
No history of trauma
No history of previous surgery
PERSONAL HISTORY:
Appetite normal
Mixed diet ( from 4 months eats only chicken)
Sleep adequate
Decreased urine output
Regular bowel movements
No known allergies
No addictions
FAMILY HISTORY:
No history of similar complaints seen in the family
TREATMENT HISTORY:
On dialysis from July 2021
Visits weekly twice for dialysis
GENERAL EXAMINATION:
No pallor
No cyanosis
No Lymphadenopathy
No malnutrition
No dehydration
No icterus
No clubbing
No edema of feet
Temperature: 98.4°F
Pulse rate: 84/min
Blood pressure: 130/70mmHg
SpO2 : 98
GRBS : 126mg%
SYSTEMIC EXAMINATION:
CVS :
No thrills
Cardiac sounds S1 ,S2 are heard
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Position of trachea central
Breath sounds are vesicular
ABDOMEN: seaphoid
No tenderness
Liver non palpable
Spleen non palpable
No free fluid
Bowel sounds present
CNS:
Patient is conscious and speech is normal
No neck stiffness
PROVISIONAL DIAGNOSIS:
CKD on MHD
Dialysis started on June 2021
Treatment:
1. Fluid restriction <1.5 lit/ day
2. Salt restriction <2g/kg
3. Tab.lasix 40mg bd
4. Tab.nicardia 10mg bd
5. Tab.nodosis 500mg bd
6. Tab.livogen -2 od
7. Tab.shelcal cp od
8. Inj.erythropoitin 4000 IV weekly once
INVESTIGATIONS:
Comments
Post a Comment