CKD-GENERAL MEDICINE SHORT CASE
January 20 2023.
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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on
Date of admission 19/01/2023
CHIEF COMPLAINT :
Patient was apparently asymptomatic 6 months back then he developed fever chills rigors with vomiting and was found to have increased creatine ( diagnosed as renal failure) later followed up after 5.1 creatine and conservative management left follow up for 4 months
History of present illness :
Patient was apparently asymptomatic 4 days back then he developed fever intermittent type, no diurnal variation
Not associated with cough, cold, burning micturation, loose stools
Vomitings,
Associated with chills and rigors
History of past illness :
15 years back he has leg pain So he used NSAIDS for 5 years he undervent hip surgery
Patient is know case of hypertension
Tab used atenolol
Not a case of diabetes
PERSONAL HISTORY :
He is farmer by occupation, he wakes up at 6am in the morning and he used do work till 9 am and takes breakfast at 9 am after he went for agriculture field, he does take lunch lat afternoon times and later at 4pm he take lunch , dinner at 7pm after at 8.30 pm he sleeps
Diet: only veg
Apatite: normal
Sleep : adequate
Bowel movement :normal
Addictions: none
Family history
NO RELEVANT FAMILY HISTORY
GENERAL EXAMINATION
Vitals:
Temp: 98°F
Respiratory rate: 28cycles/min
Pulse: 88beats/min
Blood pressure: 130/70mmHg
Sp O2 98%
GRBS: 138mg%
Systemic examination ;
By taking the consent from patient examined in a well ventilated room
Cardiac Examination
Thrills: No
Cardiac sounds: S1, S2 positive
Inspection:-
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest
Palpation:-
S1 S2 are heard
No thrills , no murmurs
Auscultation:-
Cardiac rate - 88 beats per minute
No cardiac murmurs heard
ABDOMINAL EXAMINATION
Shape of the abdomen- scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no visible sinuses and scars are seen.
No engorged veins
Palpation:
No local rise of temperature
No tenderness
No palpable mass
No organomegaly.
Percussion:
No Fluid thrill
No shifting dullness
Auscultation:
Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM
Patient is conscious, coherent, cooperatively well oriented to time and place.
Speech: Normal
Sign of Meningitis: No
Respiratory system
Position of trachea: Central
Inspection
Chest appears Bilaterally symmetrical & elliptical in shape
Respiratory movements normal
No signs of volume loss
No dilated veins, scars, sinuses, visible pulsations.
No rib crowding ,no accessory muscle usage, no drooping of shoulder.
Palpation :-
All inspectory findings are confirmed
Trachea is in central position
Chest movements-symmetric
ORAL EXAMINATION
Plaque is present
Calculus is present
PROVISIONAL DIAGNOSIS
Chronic Kidney Disease and hypertension
Investigations :
Fever chart
Serum electrolyte :
Complete urine examination:
Complete blood picture:
Serum iron:
RFT:
Blood sugar ramdom:
Pallor:
ECG:
TREATMENT
Tab lasix 40 mg
Tab orofer xt
Tab nodosis
Tab nicardia 10 mg
Tab sevelamer
Inj Erythropoietin
