Case history- 9

 "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 53 year old male patient came to the OPD with chief complaints of  fever since 25 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month back and then he noticed fever and pedal edema.

No history of decreased urine output. 

PAST HISTORY:

Patient was a known case of hypertension since 1 month.

History of tuberculosis 2 years back and used anti tubercular treatment for 6 months.

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

No history of any surgeries in the past. 

PERSONAL HISTORY:

Appetite: normal 

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 medication for hypertension.

He had not undergone any treatment prior. He is not allergic to any known drugs. 

GENERAL EXAMINATION:

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

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

There is pallor and edema of feet.



VITALS:

Temperature: 98.6°F

Blood pressure: 140/80 mm Hg

Respiratory rate: 24/ min

Spo2: 98% at room temperature 

Pulse rate: 92 beats / min

GRBS: 126 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs 

RESPIRATORY SYSTEM:

Dyspnoea- yes

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver - not palpable

Spleen- not palpable

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious 

Speech: normal 

Signs of meningeal irritation

           Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

                  SERUM IRON

                  SERUM CREATININE 

                     

                   BLOOD UREA 


               SERUM ELECTROLYTES 


             BLOOD SUGAR- RANDOM 


          ANTI HCV ANTIBODIES- RAPID



                     HBsAg- RAPID 


                         HEMOGRAM 

 DIAGNOSIS:

Chronic kidney disease on maintenance hemodialysis 

TREATMENT:

1. Tab. LASIX 40 mg BD

2. Tab. PAN 40 mg OD

3. Tab. OROFER  XT OD

4.Inj. ERYTHROPOIETIN 4000 IU weekly once 

5. Tab. NODOSIS 500mg OD

6. Tab. SHELCAL OD

7. Inj. IRON SUCROSE 100mg IV 100ml weekly  twice.

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