General Medicine case 2
25.C Ruchitha Reddy.
August 23 2021.
"This is a online E log book to discuss our patients de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patients 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 inputs .This e log also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome".
Date of Admission:17/08/2021.
A 70 years old male presented to OPD For Dialysis who is suffering from CKD.
CHEIF COMPLAINTS;
-stomach pain since 1 week
-SOB,Fever since 1 week
- decreased urine output since 1 week
HISTORY OF PRESENT ILLNESSES;
- patient was a daily wage worker,He stopped working when he was diagnosed 10 years back with a Abdominal Lump,and he underwent a surgery.Since then he is staying at home,but does his regular activities at Home.
-And Later after few days his family members noticed that there was some involuntary movements on patient right hand,they took him to hospital again and he was diagnosed as Right sided hemeplegic.(10 years back)
-2 years back he was diagnosed with Chronic Kidney Disease.
And he is undergoing Dialysis since then.
HISTORY OF PAST ILLNESS;
- 2 years back he had a history of fever and pitting edema ,loss of appetite, facial pluffiness and he visited a local hospital, there he was diagnosed as renal failure and was on medication. No decreased urine output at that time.
-History of Abdominal Surgery 10 years back.
- Suffering from Type 2 Diabetes since 20 years and was on medication
-No History of tuberculosis
-No history of asthma,epilepsy.
PERSONAL HISTORY;
-Decreased appetite
-Mixed diet
-Regular bowel and bladder movements
-Ectomorphic built, slightly malnourshied
-Disturbed sleep
-He has No Known Allergies
-No Addictions
FAMILY HISTORY;
He has no family history of DM,Asthma,Strokes, Heart disease, kidney disease
TREATMENT HISTORY;
- He has treatment history of DM,Abdominal surgery, CKD.
GENERAL EXAMINATION;
.Pallor - yes
-cyanoasis-NO
-Lymphadenopathy-NO
-Clubbing on fingers/toes -No
-Edema on Feet- Yes Pitting type of edema is seen
-Some involuntary movements are seen on right hand
VITALS;
Temperature- afebrile
BP- 120 /80mmHg
Spo2-97%
RR- 18cycles/min
GRBS-94MG%
Urine output - 35 ml( from 8 hrs)
SYSTEMIC EXAMINATION;
Cardiovascular system;
.s1,s2 are heard no murmurs
Respiratory system;
Position of trachea- central
No wheeze
Abdomen;
No tenderness, palpable mass
Central nervous system;
Patient is conscious,coherent
Speech normal
Cerebral signs;
Involuntary movements are seen on right hand.
PROVINCIAL DIAGNOSIS;
Chronic Renal Failure.
INVESTIGATIONS;
CBP;
Hb-8.2gm/dl
Total count-7100cells/cum
Neutophils-60%
Lymphocytes-10%
Eosinophils-3%
Monocytes-7%
Basophils-00%
Platelet count-2.42
Smear-normocytic normochromic anemia
RFT;
Urea-84mg/dl
Creatinine-5.1 mg/dl
Uric acid- 4.5 mg/dl
Calcium-7.0mg/dL
Phosphorus-2.3 mg/dL
Sodium-144mEq/L
Potassium-3.5mEq/L
Chloride-104mEq/L
ABG;
PH-7.40
PCo2-30.4
PO2-195
Hco3-18.5
02 saturation-98.8
Blood sugar fasting
280 mg/dl
Bacterial culture;
pus cells are not seen in urine.
Treatment;
Inj Erytropoietin 4000IU S/C weekly twice
Inj Pantop- 40 mg IV/ OD
Inj ceftriaxone 1 g IV /BD
Tab orofer XT PO/BD
Tab Nodosis-500 PO/TD
Discussion;
-Can chronic diabetes cause kidney disease?
- What is the cause for involuntary movements on right hand?
- Why renal problems are so prevalent?
Comments
Post a Comment