GENERAL MEDICINE CASE HISTORY 3

𝟳𝟴. 𝗦𝗵𝗮𝗹𝗶𝗻𝗶  𝟲𝟱 . 𝗦𝘂𝘀𝗵𝗺𝗶𝘁𝗵𝗮

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 is a case of a 32 year male patient brought to casualty with h/o 1 episode of GTCS, Associated with loss of consciousness, involuntary micturation, episodes lasting for 10 min, associated with post ictal confusion for 20min , no h/o headache, vomiting, fever. 

History of  Present illness:

H/o burning micturation, h/o B/L ureteric calculi, right renal calculi. 

Past surgical history of right PCNL URSL C DJ stenting in nov 2020,2 sessions HD Done at that time in view of post renal AKI and discharged on medical treatment. 

History of past illness:

No h/o decreased urinary output /SOB

No other complaints 

K/C/O T2DM  since 1.5 yrs. 

Personal History:

Diet : mixed

Appetite:normal

Sleep : normal

Bowel & bladder movements : normal & regular. 

Treatment History:

Past surgical  history of right PCNL URSL C DJ stenting

Family History:

No history of similar complaints in the family. 


General Examination:

Pallor

No cyanosis

No icterus

No lymphadenopathy

Vitals 

Temperature 98.6F

Pulse rate 96pmin

Respiration 22/min

Spo2 99%

GRBS 191mg%

Systemic Examination:

CVS:

No thrills 

Cardiac sounds s1 &s2 heard

No murmers

Respiratory System:

No Dysponea

No wheeze

Postion of trechea : Central

Brethe sounds: vesicular

Abdomen:

Shape of the abdomen:Scaphoid

No tenderness

Hernia orifice : Normal

CNS:

Conscious

Speech - Normal

Cranial nerves, motor system, sensory system normal. 

Glasgow scale  -15/15

Provisional Diagnosis:

Chronic Renal failure

Investigations:

                         Hemogram

                              ABG


                 Total Proteins A/G ratio

Blood sugar fasting



                  Alkaline Phosphatase 


                   Serum Proteins

                  Serum Albumin

             

              Serum Electrolytes (Na, K, Cl) 


                         HBsAg - Rapid



Complete Urine Examination (CUE) 

                      
                       Serum creatinine


                 Blood Sugar Random


           Serum Bilirubin total & direct


𝗧𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁:

Fluid restrictions 1.5 lit/day

Salt restriction 2gm/day

Injection  CEFTRIAXONE 1gm IV/BD

Tab CASIX 40mg BD

Tab NODOSIS 500mg TD

Tab SHELCAL 500mg OD

Tab OROFER BD

GRBS monitoring 6th hourly

Inj LEVIPIL 500mg IV BD

Inj HAI SC acc to GRBS

BP/PR/Temp/SPO2 monitoring. 













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