General medicine case 


 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

Date of admission : 20 November

A  48 year old male who is an  autodriver by occupation came to the OPD with the chief complaint of  decreased urinary output and facial puffiness,swelling of legs since 6 days. 

 History of present illness : 

Normal routine of the patient : 

The patient wakes up by 6AM daily, will have his breakfast by 8 AM (rice and curry), then drives auto from 9 AM to 1 PM sometimes upto 2PM, then he used to have his lunch(rice & curry or roti) and again he drives auto till evening . Then he come to home  takes rest and have his dinner between 9:30 to 10 PM and then he sleeps. 

The patient was apparently asymptomatic 5years ago, on regular check up found to be hypertensive. 

1 week ago, he developed pedal edema, progressed gradually till kness, facial puffiness, decreased urinary output, decreased appetite. 

He went to RMP ,the symptoms we're not subsided so he went to a local doctor in nalgonda, doctor suspected  renal problem and then the patient came to KIMS OPD with these complaints and was diagnosed with Chronic kidney disease.

The patient now comes to the hospital for dialysis 


History of past illness :

The patient is a known case of diabetes since 8 years

He is a known case of hypertension since 5 years

H/o acute pancreatitis 5 years ago

Personal history : 

- The patient has  loss of appetite

- He takes mixed diet

- No sleep disturbances

- smoking and drinking : he used tosmoke and drink,but stopped 5 years ago. 


Family history :

- There are no similar complaints in the family members


Treatment history :

- The patient has taken medications for hypertension and diabetes

- He is not a known case of drug allergy.


General examination :


- Patient is conscious, coherent, cooperative 

- No Pallor

-No Cyanosis

-No icterus 

- Presence of edema





Vitals:
Pulse rate:95/min
Respiratory rate :26/min
BP:180/100
Systemic Examination:
CVS:
S1, S2 sounds heard
Respiratory System :
BAE +
CNS:
Conscious
Normal speech 
Abdomen:
No tenderness
No free fluid. 
Provisional Diagnosis: CKD (diabetic Nephropathy??) 
Investigations:












TREATMENT:
T. Lasix 40 mg-morning and night 8 AM & 4 PM
Fluid retention <1.5 L/day
T. Nicardia 10 mg PO/BD
Salt restriction <4mg/day
T. Nodosis 520mg 
T. Orofer  PO/OD
T. Shellcal PO
4/12/21
Fluid restriction <

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