General medicine case-6

 This is an online e log book to discuss our patient de-identified health data shared after taking his /her /guardians signed informed consent.Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input.

This e blog also reflects my patients centered online learning portfolio and your valuable inputs on the comment box is welcome.

A 35 years  male patient ,labour by occupation came to the casualty  with shortness of breath and pedal edema since 10 months.

History of present illness:- 

-Patient was apparently asymptomatic 3 yrs back ,then he went to local hostpital due to some illness .

-There he came to know that he has high blood pressure and he taken medication for high blood pressure.

-Patient still using medication for high BP.

-As the patient using medication for BP ,he developed swelling in legs(edema )  , shortness of breath while walking ,he consulted local hostpital.

-There he was suggested to go to NIMS  1 yr back .

- There he prescribed to dialysis ,3 times dialysis was done in NIMS .

-  In NIMS  they suggested to go to nearby hospital because of lot of patients .

-Then he came to our casuality .

Past history :-

-No history of hypertension , diabetes mellitus,asthama ,epilepsy ,surgery ,blood transfusion .

Personal history:- 

-Diet :- mixed 

- Sleep :- adequate 

-Appetite :- normal 

-Bowel and bladder movements:- regular 

- Addictions :- Has a habit of alcohol intake since 10 yrs ,drinks alcohol due to work stress occasionally.

Family history:- 

- No history of similar complaints in family members.

- Patient mother has a history of TB.

Drug history :- 

-No history of drug allergy to known drugs.

General examination:- 

-Patient is conscious , coherent and cooperative , well oriented to the surroundings.

-Moderatly built and nourished .

-No pallor , icterus, cyanosis, clubbing, lymphadenopathy.

Vitals :- 

-Temperature :- Afebrile 

-pulse rate :- 98 beats / min 

- Respiratory rate :- 24 cycles /min 

- blood pressure:- 130 /70 mmHg 

-Spo2 :- 98%

- GRBS :- 126 mg %

Edema is present which is pitting type .

Systemic examination :- 

- CVS :- Palpation :- Chest wall is bilaterally symetrical .

Auscultation :- S1,S2 heard , no murmurs 

JVP normal 

- Respiratory system :- Bilateral air entry was normal .

- CNS :- Patient is well oriented to person and  surroundings  .

No abnormality detected .

Investigations :- 

ECG :- 

Provisional diagnosis :- Chronic kidney disease .

Treatment :- 

Dialysis weekly twice .

1) Fluid restriction  <1.5 L / day 

2)Salt restriction <2 gm / day 

3) Tab Lasix 20mg  BD 

4) Tab Nicardia 20 mg BD 

5) Tab Arkamine 0.1 mg TID 

6) Tab Shelcal 500mg BD 

7) Tab Orofer-xt BD 

8)Tab Nodosis 500mg BD 

9)Inj Erythropoietin 4000 IU ×SC weekly once 

10) Inj Ceftriazone 1.2 gm IU BD