A 53 year old came to casuality with C/o pedal edema since 2 months. C/O SOB Since 1 day. C/O decreased urine output since 2 months.

-
A 53 year old male came to casualty with chief 
C/o pedal edema since 2 months
C/O SOB Since 1 day
C/O  decreased urine output since 2 months.
History of presenting illness:-
Patient was apparently alright 1 year back then  he developed  decreased urine output for which he went to hospital and  was diagnosed as chronic kidney disease and was on Conservative management. 
Patient  developed decreased urine output since 2 months.
No  Hesitancy, dribbling of urine.

-History of pedal edema Since 2 months, pitting type upto knee.
-History of SOB since 1 day; Grade -IV according to MMRC  , Orthopnea present, no   PND.
No chest pain, no palpitations.

 3. HISTORY OF PAST ILLNESS

K/c/o Dm-ll Since 7 years on insulin

K/c/o HTN Snce 1 year on CILNIDIPINE 10mg.
No history of asthma ,tuberculosis ,epilepsy 

Personal history: 
Diet mixed 
Appetite normal 
Sleep Adequate
Bowel are regular
Bladder movements decreased output since 2 months.
Addictions: 
Alcohol - regular but stopped since 2 years
Smoking- 1 pack per day since 6 years.

General examination

Pat is c/c/c well oriented to time place person 

He is moderately built and nourished
Mild pallor
Icterus present 
No signs of cyanosis, clubbing, lymphadenopathy. 
Edema (pitting type) is seen over  B/L lower limbs below knee, lateral  and posterior aspect of abdomen.

Vitals 

Temperature - 98.4 F 

BP - 130/90 mm hg 

PR - 101 BPM 

RR - 28 cpm 
 
GRBS- 168 mg/dl

CVS - S1 S2 Heard no murmurs 

RS - BAE + NVBS 

CNS : NFND 

P/A : soft,
   Tenderness present over the swelling, which is developed over the lateral and posterior aspect of abdomen.
                                     











Provisional diagnosis: 
CKD on MHD
fluid overload with pulmonary edema

Investigations: 
6/10/23
7/10/23




6/10/23

O/E :
Patient is c/c/c
BP-130/90
PR-101bpm
GRBS-168mg/dl
RR-28 cpm
CVS - S1S2 +
           No murmurs
RS - BAE +, NVBS.
CNS- NFD
P/A- soft, Tenderness at the flanks

Treatment:
1. Inj. PAN 40 mg IV/OD
2. Tab. NODOSIS PO BD
3. Tab. shelcal - CT PO OD
4  TAb. OROFER-XT PO.OD
5. TAD. DOLD 650 MG PO SOS
6. GRBS monitoring
7. Monitor vitals 4th hourly

7/10/23

O/E :
Patient is c/c/c
BP-150/90
PR-98bpm
RR-18 cpm
CVS - S1S2 +
           No murmurs
RS - BAE +, NVBS.
CNS- NFD
P/A- soft, Tenderness at the flanks.
 
Treatment:
1.fluid restriction less than 1lt/day
2.salt restriction less than 1.2gm/day
3.TAB CINOD 10mg PO BD
4.inj. HAI 5 units TID aa per advice
5. 7 (.) Grbs
6.inj LASIX 40mg iv/BD
7. Tab NODOSIS 500 mg po/BD
8. Tab SHELCAL CT po/OD
9.Tab⋅ OROFER-XT. Po OD
10. INJ Iron Sucrose 200mg in 100ml NS
       Thrice weekly.
11.Inj. EPO 4K S/C twice weekly.

Comments

Post a Comment

Popular posts from this blog

my journey in the realm of general medicine department

-
Image
The General Medicine Department serves as the cornerstone of healthcare, dealing with a diverse range of medical conditions.  Embarking on my journey within the realm of the General Medicine Department has been both enlightening and transformative. This department, often considered the backbone of healthcare, encapsulates the essence of medical practice by addressing a myriad of medical conditions and providing a holistic approach to patient care. From the outset, I was immersed in the art of history-taking, recognizing its pivotal role in unraveling the intricate tapestry of a patient's health. Learning to navigate through the nuances of each patient's narrative, I discovered that the subtleties often held the key to understanding the onset and progression of their ailments. The clinical examinations became a canvas where I could observe and interpret the manifestations of various medical conditions. Each palpation, auscultation, and observation became a piece of the diagnosti
Read more

A 60yr old female came with the complaints of generalised body pains since 2 years

-
Image
 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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 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 in
Read more

A 34 year old male with vomiting , generalised weakness and hiccups

-
Image
  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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 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 i
Read more