General Medicine Case-2

 6th September 2021

This is online e-log book to discuss for patients de-identified health data shared after taking his/guardian sign informed consent

Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best based inputs

A 48 year old male patient presents to ICU with chief compliant of fever from 6months and swelling all over body since 3days ,constipated since 4days

Date of admission:4/09/2021

HISTORY OF PRESENT ILLNESS 

•Edema since 3days seen all over body

•Constipated since 4days

• Fever 6 months back 

• Weight gain is seen in the patient 

HISTORY OF PAST ILLNESS 

•No similar illness is seen in the past 

• History of diabetes mellitus and Hypertension from 3years

•Taking medication of atenolol and Amlodipine for HTN and 25 units of insulin BD

• Thyroid-hypothyroidism-since 1year

•Thyronorm(L-thyroxine-50mcg) OD

•Symptoms of hypothyroidism: Excessive       sweating, weight gain, shortness of     breath,are seen 

•No Tuberculosis 

• No asthma 

•No lymphadenopathy

•No history of trauma 

• No history of previous surgery

•No history of any radiation exposure

PERSONAL HISTORY

•Patient has normal gait 

•Appetite-normal

•Diet-normal

•Bowel and bladder movements:constipated 

•Urine output:normal

•Sleep: adequate

•Addictions: not chronic Alcoholic stopped  6months back 

TREATMENT OF DRUG ALLERGY

• No history of drug allergy 

FAMILY HISTORY

•No history of similar illness seen in the family 

GENERAL EXAMINATION

•Patient is coherent non-coperative normal gait and is not active 

• Pallor 

•No icterus

•No clubbing 

•Pedal edema-both legs

•No cyanosis 

VITALS 

•Temp:37C

•Respiratory rate:15cpm

•BP:140/90 mm/Hg

•PP:72bpm 

• Spo2-88 at room temperature

SYSTEMIC EXAMINATION

•S1 & S2-abnormally heard 

• CNS- coordinated movements

•Kidneys-inflamed and decreased blood flow there by decrease GFR 

PROVISIONAL DIAGNOSIS 

•This is a case of AKI(Acute kidney injury) ON CKD( chronic kidney disease)

INVESTIGATIONS



Complete Urine examination report




 Serum iron:


ECG



Renal function test:




Blood sugar- fasting






Treatment:
 Fluid restriction <1.5L per day
 Salt restriction <2 gm per day
Tab.Aldactone 25mg OD
 Tab.orofer xt BD
 Thyronorm: 50mcg
 Inj. HAI s/c according to GRBS
Dialysis alternate day depending on condition



Though the patient has normal serum iron levels why is he on ferrous supplements?

Is he anemic due to erythropoietin deficiency due to kidney failure?

Is kidney failure in this patient is due to hypertension?


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