03 Sai Tarun 09/10/21

 

GENERAL MEDICINE CASE 


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 3rd semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.



Introduction

65 yr old male came to the casuality with chief complaints pedal edema since 1 and half year.Decreased urine output since one and half year.

History of present illness

Patient was apparently asymptomatic for 1 and half year back then he developed pedal edema which was gradual onset progressive in nature, came to kims for further investigations.

HISTORY OF PAST ILLNESS 

K/C/O   HTN

N/K/C/O   DM,Thyroid ,TB,Epilepsy,Asthma.

PERSONAL HISTORY

•Mixed diet

•Loss of appetite

•Sleep adequate

•Bowel and Bladder movements regular.

TREATMENT HISTORY 

•k/c/o HTN 
• Not k/c/o diabetes,CAD , asthma, TB.

•NO H/O chemo /radiation , blood transfusion.

•NO H/O previous surgeries.

FAMILY HISTORY 

Not significant.

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Cyanosis

                       Clubbing

                        Icterus

                         clubbing

                        lymphadenopthy

•Pedal edema and Pallor present

VITALS
Temp: Afibrile
PR: 86bpm
BP: 130/90mm hg
RR: 22cpm

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM


CVS: s1s2 heard
•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

RS: BAE+ NVBS+

ABDOMEN
P/A: soft, non tender, bowels sounds heard

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

CNS: NFND

INVESTIGATIONS 

30/08/21































31/08/21







05/10/21







PROVISIONAL DIAGNOSIS

- CKD ON MHD

TREATMENT 

Fluid restriction <1.5L/Day

Salt restriction <2G/day

TAB NICARDIA 10MG/PO/BD

TAB LASIX 40MG/PO/BD

TAB NODOSIS 550MG/PO/OD

TAB SHELCAL 500MG/PO/OD

TAB OROFER XT PO/OD

INJ ERYTHROPOEITIN 4000IU WEEKLY ONCE


Advice on Discharge

fluid restriction <1.5L/Day

Salt restriction <2G/day

TAB NICARDIA 10MG/PO/BD for 10 days

TAB LASIX 40MG/PO/BD for 10 days

TAB NODOSIS 550MG/PO/OD for 10 days

TAB SHELCAL 500MG/PO/OD for 10 days

TAB OROFER XT PO/OD for 10 days

T.PAN 40mg PO/OD/BBF

T.BIOD3 PO/OD




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