General Medicine case 11-09-23

 GENERAL MEDICINE CASE (11-09-23)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 8th 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.

DATE OF ADMISSION - 08/08/23

CHIEF COMPLAINTS

A 55yr old male patient resident of haliya came to general medicine opd with cheif complaints of SOB since 1week,dry cough since 3days,decreased urine output since 15days.

HISTORY OF PRESENTING ILLNESS

Patient was apparently aymptomatic 6months back. Then he was on hemodialysis from6mnths back from june 2023.

Then he developed shortness of breath since 1week which is of grade 4 and insidious in onset and gradually progressive in nature which is aggrevated on talking and relieved on taking rest.

There is ARI with dry cough since 3days.

Bilateral pedal edema which is of pitting type is seen.

Decreased urine output since 15 days is seen.

HISTORY OF PAST ILLNESS

He is a k/c/o HTN sicne 6months 

K/c/o DM since 20days

Is a k/c/o CKD since 2 and half yrs 

Is k/c/o hypothyroidism from 1month.

TREATMENT HISTORY

k/c/o DM,HTN

Not a k/c/o CAD,TB,asthma,chemo,radiation.

Not a K/C/O blood transfusion (prbc-packed red blood cells).

PERSONAL HISTORY

Mixed diet

Appetite Lost

Sleep adequate

Bowel movements regular.

Micturition abnormal.

Habits-occasionally drinks alcohol

             4-5 beedis perday.

FAMILY HISTORY

Not significant 

PHYSICAL EXAMINATION

Temp- 

BP-140/80 mm hg

Pulse rate-82/min

Respiratory rate-16/min

Spo2-

GRBS-

-No signs of pallor,cyanosis,lymphadenopathy,icterus.

-pedal edema present

SYSTEMIC EXAMINATION 


CARDIOVASCULAR SYSTEM

•S1, S2 heard

RESPIRATORY SYSTEM:

•NVBS heard

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - obese

•No Tenderness

•No palpable mass

 -No fluid present.

-No palpable liver or spleen


CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

CEREBRAL SIGNS

• No finger nose incordination

•No knee heel incordination.

INVESTIGATIONS































ECG




PROVISONAL DIAGNOSIS

CKD on MHD with k/c/o Hypertension and DM

K/c/o Hypothyroidism.

TRETMENT

1.Fluid restriction <5L per day

2.Salt restriction <2gms per day

3.T.lasix 20mg po/bd

4.Inj PAN IV /OD

5.Inj ZOFER IV/OD

6.Tab AMLONG 10mg po/bd

7.T NODOSIS 500mg po/bd

8. OROFER po/bd

9. INJ NEOMOL 1g IV

10. T DOLO 650 po/bd

11. INJ ERYTHROPOIETIN IV s/c twice weekly

12. Monitor vitals 4th hourly

13. Inform SOS


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