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 the opd with the chief complaints of 

• b/l pedal edema 
• decreased urine output since 2 years 
• Abdominal distension 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years back then he suddenly developed b/l pedal edema, pitting type, gradually progressive and also complains of decreased urine output 

he then had an ulcer on the left malleous, which they treated by themselves when it burst out.

4 months back, he visited the hospital with the complaints of pedal edema and decreased urine output.

From then he came every two weeks to the hospital for the dialysis session.

No c/o shortness of breadth, palpitation, pedal edema

HISTORY OF PAST ILLNESS:

He is a known case of hypertension since 10 years 

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

TREATMENT HISTORY: 

He was on Nicardia 10mg since 10 years for his hypertension.

PERSONAL HISTORY:

• Appetite is normal
• Having mixed diet( Non vegetarian)
• Bowels- Regular
• Micturition- decreased urine output
• He has a habit of smoking since many years( bidi 2-3/day) 
• He has a habit of drinking alcohol, toddy since many years.

GENERAL EXAMINATION: 

Patient is conscious.

Pedal edema is present.

Absence of Icterus, Clubbing, Cyanosis, Pallor, Lymphadenopathy.

 

                                  

VITALS:

1.Temperature: 98.6 F

2.Pulse rate: 84 beats per min

3.Respiratory rate: 18 cycles per min 

4.BP: 100/80 mm Hg

5.SpO2: 99% @ Room air 

6.GRBS: 106mg% 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

• S1, S2 are heard 
• No murmurs 

RESPIRATORY SYSTEM:

• Normal vesicular breath sounds
• Position of trachea is central
• Dyspnoea is absent
• No wheeze

  

EXAMINATION OF ABDOMEN:

• Shape- scaphoid
• Tenderness is absent 
• 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:

CKD on MHD 

INVESTIGATIONS:

                            

ECG 

TREATMENT:

 

1. NICARDIA 10mg PO/BD
2. TAB. NODOSIS 500mg PO/OD 
3. TAB. LASIX 40mg PO/BD
4. TAB. SHELCAL CT  PO/OD 
5. TAB. OROFER×T PO/BD 
6. Inj. Erythropoietin 4000 IU/SC once weekly