GENERAL MEDICINE

GENERAL MEDICINE

NEPHROLOGY

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

DECEMBER 2 2021 

60 YEARS OLD MALE WITH CKD ON MHD WITH K/C/O HTN

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CASE HISTORY

A 60 YEAR OLD MALE , FARMER BY OCCUPATION ,CAME TO THE OPD WITH 

CHEIF COMPLAINTS OF -

PEDAL EDEMA SINCE 6 MONTHS  

SHOTNESS OF BREATH SINCE 6 MONTHS 

DECRESED URINE OUTPUT SINCE 6 MONTHS 

HISTORY OF PRESENTING ILLNESS -

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK THEN DEVELOPED PEDAL EDEMA ,WHICH WAS GRADUALLY PROGRESSIVE ,A/W DECREASED URINE OUT PUT AND A/W SOB AND THEN CAME TO KIMS FOR FURTHER EVALUATION NO C/O OF CHEST PAIN ,PALPITATION ,GIDDINESS ,FEVER , COLD ,COUGH ,BURNING MICTURATION 

PAST HISTORY - 

K/C/O OF HTN SINCE YEARS ON TAB 

NOT A KNOWN CASE OF DM ,  EPILEPSY , ASTHMA , TB

PERSONAL HISTORY :

DIET - MIXED ,APPETITE -NORMAL  ,BOWEL MOVEMENT - REGULAR  ,  BLADDER MOVEMENTS - IRREGULAR (DECREASED URINE OUTPUT) , ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

FAMILY HISTORY - 

NAD

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALLOR , ICTERUS , CLUBBING , CYANOSIS , LYMPHADENOPATHY ,  EDEMA

VITALS - 

TEMPERATURE - AFEBRILE

PULSE RATE - 98 BPM

BLOOD PRESSURE - 140/90 MM OF HG 

RESPIRATORY RATE - 20

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR  SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

INVESTIGATION - 

RBS - 144 MG/DL

BLOOD UREA - 99 MG/DL

SERUM ELECTROLYTES  -  SODIUM - 141 MEQ /L , POTASSIUM - 3.3 MEQ /L , CHLORIDE - 98 MEQ / L

HAEMOGLOBIN  - 9.9 GM/DL

COMPLETE URINE EXAMINATION  NO ABNORMAL VALUE DDETECTED 

SERUM CALCIUM  - 10 MG/DL

PHOSPHORUS   - 3.9 MG/DL

COLOUR DOPPLER 2D ECHO  - 

NO AR/MR/TR /AS

NO RWMA

GOOD LEFT SYSTOLIC FUNCTION 

DIASTOLIC DYSFUNCTION ,NO PAH OR PE 

SEROLOGY -HBSAG -RAPID,HIV 1/2 RAPID TEST ,ANTI HCV ANTIBODIES - NEGATIVE

BLOOD GROUPING AND RH TYPING - O POSTIVE 

URIC ACID SERUM -   10.6 MG%

SERUM CREATININE - 5.7 MG/DL

ULTRASOUND ABDOMEN AND PELVIS  -   IMPRESSION - B/L GRADE 1 - 2 RPD 

TREATMENT GIVEN -

1 . T .NICARDIA 10 MG /PO/OD  1--X--X IF SBP >130

2. T .NODORIS 500 MG PO /BD 1 --X--1

3 . T.SHELCAL PO/OD X --1--X

4.T. OROFER XT PO/OD 1--X--1 

5.INJ . ERYTHROPOETEIN 4000 IU 8/6 WEEKLY ONCE 

6.FLUID RESTRICTION (1L/DAY)

7.SALT RESTRICTION <4GM/DAY 

8.INFORM SOS 

9.MONITOR BP 2 ND HOURLY

CLINICAL IMAGES AND LAB REPORT