General medicine case 1

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A 45 years old man presented to the OPD with cheif complaints of Swelling of both the legs and Shortness of breath from past 2 months.

HISTORY OF PRESENT ILLNESSES

Patient was apparently asymptomatic 4months back

Then he complained of Bilateral Pedal Edema which was gradually progressive,pitting type,below the knee.                                           

 He also complained Shortness of breath(Grade2)and pain in the legs. Then they went to nearest medical care and daignosed with kidney problem and was started on medication

6 days back patient presented to the casuality with swelling in the legs and shortness of breath for which he adviced to undergo dialysis

3 dialysis units have been done till 10/8/21

HISTORY OF PAST ILLNESSES

Patient is a known case of HTN from past 1 year

Not a known case of DM,TTS,Asthama and Epilepsy

No history of surgeries and blood transfusions in the past

FAMILY HISTORY

Patient's father was known case of B.P

Patient's mother was a known case of Sugar and B.P

No history of CVA,CAD, Asthama and Thyroid disorder in the family

GENERAL EXAMINATION

Patient is conscious, coherent, cooperative

There is Pedal Edema

No pallor,clubbing,koilonychia and lymphadenopathy

VITALS

Temperature: 37.5°C

Pulse rate: 80/min

Respiratory rate: 16breath/min

BP : 110/80 mmHg

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Chest wall is bilaterally symmetric

No precordial bulg

No visible pulsations, engorged veins,scars and sinue

PALPATION

Apex beat : felt in the left 5th intercostal space in mid clavicular lin

AUSCULTATION

S1 and S2 heared

RESPIRATORY CYST

Position of trachea - centre

Bilateral air entry :+

Normal vesicular breath sounds - heared

PER ABDOMINAL

Abdomen distended,soft and non tender

Bowel sounds heared

No palpable mass or free fluid

CENTRAL NERVOUS SYST

Patient is conscious, coherent,coperative with normal speech

and

No signs of meningeal irritation

Sensory and motor reflexes: intact

PROVISIONAL DIAGNOSIS

Chronic renal failure

INVESTIGATION

LFT 

Total bilirubin: 0.81 mg/dl

Direct bilirubin: 0.20 mg/dl

SGOT: 12 IU/L

SGPT: 10 IU/L

Alkaline phosphatase: #283 IU/L

Total proteins: # 6.3 gm/dl

Albumin: 3.6 gm/dl

Phosphorus: #6.0 mg/dl

Calcium: 9.4 mg/dl

Serum iron 72 micro g/dl

RBS : 109 mg/dl

Blood urea : # 97 mg/dl

Serum creatinine : # 7.5 mg/dl

SERUM ELECTROLYTE

Sodium: 137 mEq/L

Potassium: 4.4 mEq/L

Chloride : 99 mEq/L

CBP

ECG

CUE

CLINICAL DIAGNOSIS

REPORT

TREATMENT

   Since patient has Hb 6.6 gm/dl he undervent blood transfusion (PRBC) on 08/08/21 

    1. Tab. NICARDIA R 6 TARD 20mg PO/BD

    2. Tab. NODOSIS 500mg PO/OD 

    3. Tab. OROFER XT PO/BD 

   4. Tab. SHELAC AC CT PO/BD 

   5. Inj. ERYTHROPOIETIN 4000 IO.    

         S/C weekly twice

   6. Inj. IRON SUCROSE 10mp in 50ml        

     NS/IV/ Weekly once.  

   7. Fluid restriction < 1.5 L/day.   

   8. Salt restriction < 4 gm/day 

   9. T. LASIX 40 mg PO/BD

POSSIBLE QUESTIONS TO ASK PATIENT

1,When was the first time he undergone              Dialaysis?

2,How frequently he undergoes dialysis?

3,Did his symptoms reduced after   undergoing Dialysis?