GENERAL MEDICINE

 GENERAL MEDICINE

NEPHROLOGY

This is an 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 clinical problems with collective current best evidence based input.
 
A 60 year old male, Farmer by occupation, came to the OPD with chief complaint of Pedal Edema since 6 months, Shortness of breath since 6 months, Decreased urine output since 6 months.

HISTORY OF PRESENTING ILLNESS -

PATIENT WAS APPARENTLY ASYMPTOMATIC 6 MONTHS BACK THEN DEVELOPED PEDAL EDEMA ,WHICH WAS GRADUALLY PROGRESSIVE, DECREASED URINE OUT PUT  AND THEN CAME TO KIMS FOR FURTHER EVALUATION NO COMPLAINT OF CHEST PAIN ,PALPITATION ,GIDDINESS ,FEVER , COLD ,COUGH.

PAST HISTORY - 

K/C/O OF HYPERTENSION SINCE YEARS ON TAB 
NO HISTORY OF EPILEPSY, ASTHAMA, TB. 

PERSONAL HISTORY :

DIET - PATIENT CONSUMES MIXED DIET,APPETITE -NORMAL  ,BOWEL MOVEMENT - REGULAR  ,  BLADDER MOVEMENTS - IRREGULAR (DECREASED URINE OUTPUT) , ADDICTIONS - PATIENT IS NON ALCOHOLIC.

FAMILY HISTORY - 
NAD

GENERAL EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE
NO PALLOR , ICTERUS , CLUBBING , CYANOSIS , LYMPHADENOPATHY ,  EDEMA

VITALS - 

TEMPERATURE - AFEBRILE
PULSE RATE - 98 BPM
BLOOD PRESSURE - 140/90 MM OF HG 
RESPIRATORY RATE - 20
SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR  SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
CENTRAL NERVOUS SYSTEM : NAD

INVESTIGATION - 





RBS - 144 MG/DL
BLOOD UREA - 99 MG/DL
SERUM ELECTROLYTES  -  SODIUM - 141 MEQ /L , POTASSIUM - 3.3 MEQ /L , CHLORIDE - 98 MEQ / L
HAEMOGLOBIN  - 9.9 GM/DL
COMPLETE URINE EXAMINATION: NO ABNORMAL VALUE DDETECTED 
SERUM CALCIUM  - 10 MG/DL
PHOSPHORUS   - 3.9 MG/DL 
BLOOD GROUPING AND RH TYPING - O POSTIVE 
URIC ACID SERUM -   10.6 MG%
SERUM CREATININE - 5.7 MG/DL 


CLINICAL IMAGES AND LAB REPORT :

BLOOD SUGAR:



BLOOD UREA:



HAEMOGLOBIN:


COMPLETE URINE EXAMINATION: 









SERUM CREATININE:


ECG:




TREATMENT GIVEN -

1 . T .NICARDIA 10 MG 
2. T .NODORIS 500 MG 
3 . T.SHELCAL 
4.T. OROFER XT  
5.INJ . ERYTHROPOETEIN 4000 IU 8/6 WEEKLY ONCE 
6.FLUID RESTRICTION 
7.SALT RESTRICTION 

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