GENERAL MEDICINE E-LOG

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 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 evident based input. 

CHIEF COMPLAINT:

A 65 year old male came to opd with the chief complaints of 

• Pedal edema and 
• Dyspnea on exertion( Grade III) since 10 days 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 10 days back, then he developed pedal edema and he was having dyspnea on exertion which is of grade III. 

No bleeding manifestation

No c/o burning micturition 

No c/o cough, cold, headache

HISTORY OF PAST ILLNESS:

He was diagnosed with Acute Kidney injury in the past for which 4 sessions of hemodialysis were done.

Not a k/c/o DM, Hypertension, Asthma, TB, epilepsy.

TREATMENT HISTORY:

Past treatment history includes 4 sessions of hemodialysis, which were done to treat his Acute Kidney Injury. 

No treatment history of DM, Hypertension, Asthma etc 

PERSONAL HISTORY:

• Appetite is lost 
• Having mixed diet( Non vegetarian) 
• Bowels- regular
• Micturition- normal
• Alcohol intake- occasional 
• Has a habit of smoking  bidi 2-4 per day 
• No other habits/ addictions 

GENERAL EXAMINATION:

Patient is conscious.

Pallor is present.

Absence of Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Temperature: 98.2 F

2.Pulse rate: 98 beats per min

3.Respiratory rate: 24 cycles per min 

4.BP: 140/90 mm Hg

5.SpO2: 98% @ Room air 

6.GRBS: 118mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 heard
• No thrills, No murmurs

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnea is present
• No wheeze

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• No tenderness
• No palpable pass
• Normal hernial orifices 
• No free fluid
• No Bruits
• Liver is not palpable
• spleen is not palpable
• Bowel sounds heard

CENTRAL NERVOUS SYSTEM:

• Patient is conscious 
• Speech is normal 
• No focal neurological defect

PROVISIONAL DIAGNOSIS:

Chronic Kidney Disease(CKD) on MHD

? Denovo Type 2 DM 

INVESTIGATIONS:

Investigations on 30/09/21:

                                

Blood sugar- Random

Serum Electrolytes 

Serum Creatinine 

Blood urea

Investigations on 1/10/21:

                                 

CUE

ECG

Hemogram

HIV 1/2 Rapid test

Anti HCV Antibodies- RAPID

HBsAg-RAPID

BLOOD GROUPING and RH TYPE 

Investigation on 4/10/21:

                                  

Serum Iron 

Investigation on 5/10/21:

                          

RFT 

                                  2D ECHO 

TREATMENT:

Treatment on 1/10/21:

1. TAB. LASIX 40mg PO/BD
2. TAB. PAN 40mg PO/OD
3. TAB. OROFER×T PO/BD
4. FLUID RESTRICTION < 1.52/day 
5. SALT RESTRICTION < 2gm/day 
6. TAB. SHELCAL 500mg PO/OD
7. Inj. Erythropoietin 4000 IU/SC one weekly

Treatment on 2/10/21:

1. FLUID RESTRICTION< 1.5L/day
2. SALT RESTRICTION< 2gm/day
3. TAB. LASIX 40mg PO/BD
4. TAB. PAN 40mg PO/OD
5. TAB. OROFER×T PO/BD 
6. TAB. SHELCAL 500mg PO/OD 
7. Inj. Erythropoietin 4000 IU/SC once weekly 
8. GRBS 6 Hrly

Treatment on 3/10/21:

1. FLUID RESTRICTION< 1.5L/day
2. SALT RESTRICTION< 2gm/day
3. TAB. LASIX 40mg PO/BD
4. TAB. PAN 40mg PO/OD
5. TAB. OROFER×T PO/BD 
6. TAB. SHELCAL 500mg PO/OD 
7. Inj. Erythropoietin 4000 IU/SC once weekly 
8. GRBS 6 Hrly

Treatment on 4/10/21:

1. FLUID RESTRICTION< 1.5L/day
2. SALT RESTRICTION< 2gm/day
3. TAB. LASIX 40mg PO/BD
4. TAB. PAN 40mg PO/OD
5. TAB. OROFER×T PO/BD 
6. TAB. SHELCAL 500mg PO/OD 
7. Inj. Erythropoietin 4000 IU/SC once weekly 
8. GRBS 8 Hrly

Treatment on 5/10/21:

1. TAB. LASIX 40mg PO/BD
2. TAB. PAN 40mg PO/OD
3. TAB. OROFER×T PO/BD 
4. TAB. SHELCAL 500mg PO/OD
5. GRBS  6 Hrly