General medicine case 2



 Date of admission:15/08/2021

Cheif complaint:

 A 50 years old women who is a daily wage worker came to causality with cheif complaint of sob since 3months,pedal edema and decreased urine output since one year 

History of present illnesses:

  Patient was apparently asymptomatic 1year back then developed pedal edema which was gradually progressive and associated with sob with decreased urine out put.

Past history:

 No similar complaints in the past .

No diabetes. 

Hypertension is present 

No asthma 

No TB

No blood transfusions 

No history of surgery in past 

No epilepsy  

   Personal history:

  Diet:abnormal 

  Appetite:normal 

  Bowel :regular 

  Bladder: irregular 

 No addictions.

Family history:

No history of similar compalinents in family 

Drug history 

No allergy to known drugs 

General examination:-

Patient is conscious, cooperative and coherent

Pallor is present 

No cyanosis 

No lymphadenopathy 

No dehydration 

No clubbing of fingers 

Vitals:

Temperature:98°f

Bp:140/90

Pulse rate:100/min

Respiratory rate:22/min

Systemic examination:- 

 Cvs

 S1 and S2 sounds are heard. 

  Respiratory system:

 Position of trachea:central 

No dysponea 

 Breath sounds:vesicular 

 Abdomen:

    Abdomen is scaphoid,tenderness is not present, no palpable mass is present. 

  CNS:

  Patient is conscious 

  Speech is normal 

  No neck stiffness 

  Provisional diagnosis:

    Ckd on mhd 

Investigations:

 Blood urea--117mg/dl 

Serum creatinine-- 8.0 mg/dl 

RFT:- 
Urea -- 117 mg/dl 
Creatinine-- 8.0mg /dl 
Uric acid --10mg/dl 
Calcium--8.2 mg/dl
Phosphorus--2.3 mg/dl 
Sodium--- 131mEq/L 
Potassium-- 3.2mEq/L 
Chloride--- 95 mEq/L 
  Serum Electrolytes:-
Iron : 81.2ug/dl
 
 Hemogram:-
Hemoglobin-- 4.7 GM/dl 
Lymphocyte-- 7% 
RBC Count-- 3.58 millions/ cumm
Platelet Count-- 1.40lakhs/ cumm
  Blood grouping:
 B+ve
    
ECG




   Treatment:
     
T.Nicardia 10mg po/bd
T.Nodosis 500mg po/bd
T.Orof6RXT po/bd
T.SH6LCAL CT po/bd
Inj Erythropoietin 4000IO
Fluid restriction <1.5 L/day
Salt restriction <4mg /day
T.Riboflavin 10mg po/bd
BPLEX FORTE po/bd
Inj monocyl Ig/IV/BD
 



Comments

Post a Comment

Popular posts from this blog

GM case 9

Image
  This is an 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 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 the comment" A 27 year old male who is student from nalgonda came to the opd with chief complaints of pedal edema  since 2years . He also had vomiting and decreased urine output since 1mon History of present illness:   Patient was apparently asymptomatic 2yrs back then he developed persistent vomiting for about 2mon ,then he noticed bilateral pedal edema of pitting type which is insidious in onset ,for which he visited to local hospital and got to be told have some kidney issue and received med
Read more

GM CASE 6

Image
  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 inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome". K.meghana 39 , k.Sai likhitha 37  Date of admission:18/09/2021  39 years old male who doesn't have any proper occupation came with the chief complaints of abdominal discomfort and SOB since 3days.   History of present illness:   Patient has similar complaints since 5 years . Before diagonosing he had fever and loss of appetite since 1mon and also with cough, cold and throat infection along with back pain  and he visited local hospital where they identified is creatinine hig
Read more

GM case -4

Image
 Date of admission : 9 /08/2021 A 60 year old male who is an agriculture worker came with cheif complaint of swelling of hands and leg , shortness of breath since 1year . History of present illness:   Patient was asymptomatic 1year back before  he developed swelling of legs and hand but he neglected it later so it become progressive with  shortness of breath and decreased urine output.   Past history: Decreased urine output 1year back   Hypertension since 3years. No history of diabetes No histoy of epilepsy No history of tb No history of any previous surgeries  Personal history: Diet -mixed Sleep-decreased Appetite-decreased Bladder-regular Bowel: regular No addictions.  Family history:  No similar complaints in the family are seen. Drug history:  No allergy to known drugs.  General examination:    Patient is coherent,cooperative,conscious.    No pallor     No cyanosis    No lymphadenopathy   No malnutrition     No pedal edema   No clubbing of fingers.   Vitals:  Temp :98.4°f  Pulse ra
Read more