Case history- 6

 " This is an online E- log book to discuss our patient's de- identified health data shared informed 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. This E- log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."

A 55 year old female patient came to OPD with chief complaints of shortness of breath  and swelling of the legs since 3 days and fever associated with chills since 1 day.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 days back  and then she noticed shortness of breath  and pedal edema since 3 days.

She also complaints of fever associated with chills from  1 day.

Patient had history of diabetic nephropathy, 5 sessions of hemodialysis done.

PAST HISTORY:

Patient is a known case of diabetic mellitus and hypertension since 15 years.

No history of CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of surgeries in the past.

PERSONAL HISTORY:

Appetite: lost

Diet: mixed

Sleep: adequate 

Bowel and bladder movements: regular

Micturition: normal 

Addictions: no

FAMILY HISTORY:

There is no history of similar complaints in the family. 

TREATMENT HISTORY:

Patient was on regular medication for diabetes and hypertension. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

There is no signs of icterus, cyanosis, clubbing and generalised  lymphadenopathy.

There is pallor and pedal edema.




VITALS:

Temperature: 101.1°F

Blood pressure: 140/80 mm Hg 

Respiratory rate: 24/min

Spo2: 98% at room temperature 

Pulse rate: 98 beats/min

GRBS: 208 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard 

No cardiac murmurs 

RESPIRATORY SYSTEM:

No dyspnoea 

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen-  obese

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver- not palpable 

Spleen- not palpable 

Bowel sounds- no

CENTRAL NERVOUS SYSTEM:

Level of consciousness: alert

Speech: normal 

Signs of meningeal irritation 

              Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

                        RFT


                      LIVER FUNCTION TEST 


                  SERUM IRON 


                
HBsAg- RAPID 



   COMPLETE  URINE EXAMINATION 



                      HEMOGRAM 

         
              BLOOD SUGAR- RANDOM


                ECG


DIAGNOSIS:

Chronic kidney disease on maintenance hemodialysis 

TREATMENT:

1. Salt restriction <2gm/ day

2. Fluid restriction <1.5 l/day

3. Tab. Nicardia 20 mg TID

4. Tab. Arkamine 0.1mg TID

5. Tab. MET-XL 50mg OD

6. Inj. HAI SC/ TID 4U- 4U- 4U

7. Inj. Erythropoietin 4000 IU/SC

8. Tab. Shelcal 500mg OD

9. Tab. Nodosis OD

10. Tab. Orofer XT OD




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