1801006057- SHORT CASE

 This is an online E log to discuss our patients de-identified health data shared after taking his/her/guardians 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 problem with collective current best evidence based inputs.


This E log book also reflects my patients-centered  online learning portfolio and your valuable inputs on the comment box is welcome.


65 yr old male from Nalgonda farmer by occupation came to the hospital for maintenance dialysis 


HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 20 years back then he noticed yellowish discolouration over sclera and urine and decreased urine output then he went to a hospital.Investigations are done and  diagnosed as Jaundice.


At the same time he also diagnosed as right kidney damage. so that 3 episodes of dialysis was done in a week.

For the next 10 years he was normal.

 After 10 years he went for a normal check up and he diagnosed with diabetes and Hypertension.From then he is on medications.

For 8 years he is on oral diabetic drugs.And from  2 years he is on insulin.( Human Actrapid insulin along with Lantus )

2 months back he came to the hospital with decreased urine output and pus the urine, SOB (grade 1), back pain . For which he came to know that there is left kidney damage. From then he is on dialysis twice a week. Till now 13 episodes are done.


3 days back there is decreased urine output, back pain for which he came to the hospital.


 PAST HISTORY

Known case of Diabetes and Hypertension since 10 years


PERSONAL HISTORY 

Routine history :He wakes up at 6 am in the morning and eats breakfast at around 9 am and works as shopkeeper and then lunch at 1pm takes a nap in the afternoon. Drinks tea in the evng and chapathi as dinner at 8 pm. Sleeps at 10 pm.


  Diet : Mixed

  Appetite: Good

  Bowel and bladder movements: Regular

  Sleep : Adequate

  Addictions : Consumption of alcohol since 40 years and   stopped 15 years back 

   No smoking.


GENERAL EXAMINATION 

      Patient was conscious, cooperative.Moderetly built and nourished.Well oriented to time, place and person.


 pallor present

No icterus 

No Cyanosis

No clubbing 

No generalized lymphadenopathy

 Pitting Pedal edema present





VITALS

Temperature ;  afebrile


RR;20cycles/min   


PULSE;80bpm


GRBS;210mg%


Spo2; 100 at room temperature


BP; 130/80 mm Hg


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM 

     s1 and S2 are heard ,no murmurs are heard


RESPIRATORY SYSTEM 

    trachea central, 

    all quadrants of chest moves equally with respiration.

    Breath sounds- bilateral normal

    Vesicular breath sounds are heard.



CENTRAL NERVOUS SYSTEM 

     Patient was conscious, coherent and cooperative

     Speech was normal.

     No slurred speech.


ABDOMINAL EXAMINATION 


Inspection:

       On inspection abdomen is flat, symetrical,and slightly distended.

   Umbilicus is centre and inverted

   No scars,engorged veins are seen.

   All 9 regions of abdomen are equally moving with respiration.


Palpation:

      On palpation abdomen is soft and non tender

.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.


Percussion:no shifting dullness, no fluid thrills

.

Auscultation:normal bowel sounds are heard.




INVESTIGATIONS:



PROVISIONAL DIAGNOSIS: CKD

Treatment:

Salt restriction less than 2.4 gm /day

Fluid restriction less than 1 litre/day

Tab Nodosis po/Bd

Tab shelcal po/Bd

Orofer XT po/bd

Tab Lasix po/Bd

Tab biop3 weekly once.













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