General medicine case-5

 8th November 2021

This is an online e-log book to discuss our patients deidentified health data shared after taking his /her/ guardian informed consent here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

A 60 yr old male who is a farmer by occupation and works for 6hrs a day in the field has presented to the opd he is a known case of kidney failure and has been undergoing dialysis past 1year

CHIEF COMPLAINT:

Patient complaints about swelling of leg and weakness since 1year 

HISTORY OF PRESENT ILLNESS:

Patient has been diagnosed with increased serum creatinine levels and kidney failure a year back in the local hospital and was suggested dialysis.

Patinet is experiencing SOB from 1 month

PAST HISTORY:

Patient is undergoing dialysis from 1year

H/o Hypertension from 5years

H/o diabetes mellitus from 3years

No h/o tuberculosis

No h/o asthma 

No h/o of previous surgery

No known drug allergy 

PERSONAL HISTORY

Diet- mixed 

Appetite-normal 

Sleep-adequate 

Urine output- decreased 

Bowl movements-normal 

No regional lymphadenopathy 

No h/o similar illness in the family 

Alcohol since 10yrs( occasional)

GENERAL EXAMNATION 

Patient is conscious coherent cooperative

Pallor-present 

Cyanosis-not seen 

Clubbing-not present 

Icterus-not seen 

No dehydration 

No malnutrition 

All vitals are normal 

SYSTEMIC EXAMINATION 

CVS- S1&S2 sounds-normal 

Position of trachea -normal 

Bowl sounds- not heard 

CNS-coordinated movements 

PROVISIONAL DIAGNOSIS: 

CHRONIC KIDNEY DISEASE ON MHD 

INVESTIGATIONS:

Blood urea levels are elevated to 52mg/dl 

Serum creatinine levels:4.2mg/dl 

Hb levels-6.7gms (normocytic normochromic anemia)

WBC and Platelets-adequate 






Treatment: 

Fluid restriction 

Salt restriction 

Shellcall-500mg 

Orofer xt- 200mg 



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