CKD CASE

CASE SCENARIO 

Patient aged 62 yrs,toddy Tree climber by occupation came to opd with complaints
Of loss of appetite and nausea since one week,
Decreased urine output since 5 days
And SOB on exertion and B/L limb swelling since a week

HISTORY OF PRESENT ILLNESS

Since a week pt has loss of appetite and nausea 
SOB on exertion and B/L limb swelling since a week
Decreased urine output since 5 days


HISTORY OF PAST ILLNESS

Pt was apparently normal 4 yrs back then he developed weakness and pain of bilateral limbs and on medication with pain killers on which the pain was not subsided then xray of spine was done and pt was diagnosed with Decreased bone density (OSTEOPOROSIS)
Pt diagnosed with HYPERTENSION and on hypertensives
Not a k/c/o of DM,CAD

TREATMENT HISTORY 
Pt was on hypertensives and had a tablet daily once

PERSONAL HISTORY

Irregular bowel habit
Decreased urine output
Mixed diet 
Occasional alcohol drinker
Had smoking habit

PHYSICAL EXAMINATION 

Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

                       Icterus

Edema of feet is present 


VITALS


•Temp - 98.4F

•Pulse rate - 80 BPM

•RP - 20/min

•BP - 140/70 mm hg

•SPO2 - 96

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

Pt has Dyspnoea 

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

INVESTIGATIONS 

S.Creatinine -9.9 mg/dl

Blood Urea-149 mg /dl

Urine is albumin +










PROVISIONAL DIAGNOSIS 

CRF

TREATMENT 


Supportive treatment is given

●Tab LASIX 40 mg/BD

●Tab PAN 40mg /OD

●Tab NODOSIS 500 mg/OD

●Tab SHELCAL 500mg/OD

●Tab MVT

●BP/TEMP/PR/SP02 monitoring 4th hrly

●GRBS 12th hrly








Comments

Post a Comment

Popular posts from this blog

vignesh

Image
  GENERAL MEDICINE CASE PRESENTATION Vignesh Roll no:- 05 3rd semester  This is 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 patients clinical problems with collective current best evidence based inputs.This e-log also reflects patients centered learning portfolio. ●Case scenario  A 49 yr old female patient came to opd with the chief complaints of Shortness of breath(SOB) -grade IV and worsening  History of present illness •SOB -5 to 6 months On exertion •Pedal edema and facial puffiness since 5 to 6 months •Red urine output •Fever -10 days -subside on medication-intermittent and low grade •cough with sputum since 10 days History of past illness •k/c/o Hypertension-1 yr Treatment History  Hypertension Treatment since 1 yr •Temla 40  mg tab Personal H
Read more

5 A vignesh

  B I M O N T H L Y    B L E N D E D  A S S E S S M E N T  [JUNE 2021] Name: A vignesh, MBBS [3rd Semester] ROLL NO: 05 Question 1: Competency tested for peer to peer review and assessment: I have been given the following assignment in an attempt to read, comprehend, analyze,reflect, clinical data including history, clinical findings,investigations and diagnosis.  ANSWER 01 Case 1 Review 1  https://caseopinionsbyrollno05.blogspot.com/ PULMONOLOGY  https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html   the given case shows chief complaints of shortness of breath, pedal edema and facial puffiness. The case is very well presented and easily understandable GASTROENTEROLOGY  Case 2 Review  https://caseopinionsbyrollno05.blogspot.com https://caseopinionsbyrollno05.blogspot.com/2021/05/medicine-blended-assignment-may-2021.html      A 29 year old patient presented to hospital with developing abdominal pain and also vomitings which was suddn in onset .He
Read more

70 yr old male

Image
 Date of admission-12/09/23 Case scenario  A 70 yr old male resident of yadadri came to opd with  Chief complaints of -c/o burning micturition 15 days -c/o fever since 10 days -c/o blood in urine since a week -c/o urinary incontinence 1 week History of present illness Patient was apparently asymptomatic 15 days ago then he had burning micturition which is insidious in onset following he had fever which is associated with chills and rigor since 10 days which is relieved on medication  Pt complaints of blood in urine and urinary incontinence since 1 week Past history: *Details of patient's past history*  Pt was apparently symptomatic till 2014 then he developed blood in urine and urinary incontinence for which he visited hospital on 1st Feb 2014 following visit   *Ultrsonograpy of abdomen and pelvis done*  IMPRESSION; •diffuse urinary bladder wall thickening Significant right parailiac nodes  *CYSTOSCOPY EXM:* bladder growth specimen is collected IMPRESSION Urothelial(transitional) c
Read more