GM - E LOG :53 yr old male patient

 53 yr old male patient with chronic kidney disease 

NOTE

This is an ongoing case and will be updated .

The reference link (if any) will be mentioned at the bottom.

Date of admission: 18/10/21

HISTORY OF PRESENT ILLNESS- 

  • 53 year old male presented to the casualty with the history of CKD.
  • Daily routine before CKD: 
  • The patient was apparently asymptomatic 4 years also when he used to work in agricultural fields.
  • He used to consume alcohol  ( toddy) since childhood and he started smoking since 20 years.
  • Daily routine after CKD ( 4 yrs back ):
  • The patient was mostly staying at home and occasionally going out for his agricultural work.
  • He left smoking and drinking since 4 yrs . 
  • The patient also had history of tuberculosis (4 years back ) and hypertension ( since 1 month).
  • He has undergone hemodialysis 4 times in 25 days.


PAST HISTORY:
  • history of tuberculosis 4 years back ( used ATT for 6 months ) 
  • HYPERTENSION since 1 month
  • no history of  diabetes , CAD ,asthma
  • no history of surgeries, radiation ,blood transfusion
PERSONAL HISTORY:
  • Married
  • Occupation : agricultural worker 
  • Diet: mixed. ( Non vegetarian)
  • Appetite:  normal
  • Sleep: Adequate
  • Micturition: Regular
  • Habits/ addictions
  • Alcohol - toddy consumption 
  • Smoking ( since 20 yrs of age)
FAMILY HISTORY:
  • Not significant 
  • No history of diabetes, hypertension, heart disease , cancer , tuberculosis or asthma

GENERAL EXAMINATION:
  • Patient is conscious, coherent, co-operative.
  • He is well oriented to time, place and person. 
  • He is thin built. 
  • Pallor - present
  • No icterus
  • No cyanosis
  • No clubbing
  • No lymphadenopathy
  • No Edema.

VITALS :
  • BP: 140/80 mmHg
  • PR: 92bpm
  • Respiration Rate: 24/min
  • Temp: 98.6 F 
  • SpO2 : 98% at RA
  • GRBS : 126mg% 
SYSTEMIC EXAMINATION:

 CARDIO VASCULAR SYSTEM:

• S1 and S2 are heard, no murmurs  heard.

RESPIRATORY SYSTEM:

  •   dyspnoea present
  •    Position of trachea : central 
  •    Breath sound : vesicular 
  •    No wheezing 

   

ABDOMINAL EXAMINATION:
  •   Shape of abdomen : scaphoid
  •   Tenderness : not present
  •    No  Palpable mass 
  •    Liver not palpable
  •    Spleen not palpable
  •    Bowel sounds are heard 


  



CENTRAL NERVOUS SYSTEM:
  •       reflexes are elicited.
  •        Conscious
  •        Speech normal 
  •        No neck stiffness
  •        Cerebral signs
  •        No Finger nose in-coordination
  •        No knee heal in-coordination 
  •    
      
      PROVISIONAL DIAGNOSIS: Chronic kidney disease on MHD 

TREATMENT
  •       Tab LASIX 40 mg PO/ OD
  •       Tab PAN 40 mg PO/OD
  •       Tab OROFER XT PO/OD
  •        Inj erythropoietin 4000IU/SC weekly once 
  •       Tab OROFER XT PO/OD
  •       Tab NODOSIS 500 mg PO/OD
  •       Tab SHELCAL PO/OD
  •       Inj iron sucrose 100 mg iv 
  •      100 ml NS/IV weekly twice 
  •    

Comments

Post a Comment

Popular posts from this blog

39 year old male patient from West Bengal

Image
This is a case of a 39 year old bus driver who is a resident of West Bengal. CHIEF COMPLAINT : Abdominal distension since 2 months. Swelling in the leg since 2 months. Decreased appetite since 2 months. Decreased urine output since 1 month.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type. After a month his urine output got decreased still he continued his work as a bus driver. His relatives started noticing that his abdomen is getting distended and his appetite is decreased. They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension
Read more

OSCE and Learning points

Image
OSCE AND LEARNING POINTS PREFINAL PRACTICAL EXAMS NAME : VAGISHA RANI ROLL NO: 138 DATE: 4 December '23 Blog link: https://vagisharani.blogspot.com/2023/12/48-year-old-male-patient-from-west.html QUESTIONS  1) West haven criteria clinical grade for hepatic encephalopathy. 2) Wilson's disease and cirrhosis of liver  Wilsons diease is an inborn errors of copper metabolism characterised by increased total body copper. Etiology: Molecular defect within the copper transporting ATPase encoded by gene ( ATP7B) located on chromosome 13 Pathology:  Copper enters the body through the digestive tract with the help of a transporter protein in the cells of the small bowel, copper membrane transporter 1 (Ctr1; SLC31A1).  In response to rising copper levels, an enzyme called ATP7A releases copper into the portal vein to the liver. Liver cells carry the CMT1 protein and metallothionein, and then ATOX1 binds it inside the cell. Once here, ATP7B links the copper to ceruloplasmin and
Read more

65 year old male

Image
65 year old male from beemanapally Date of admission 21/7/23 65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year.  History of present illness:   Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking. Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area. Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep.   Past illness: Diabetes since 15 years. Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness. History of Trauma 4 years back, then he had a fall while taking his cattle to the field due to which the patient experienc
Read more