General medicine case

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Here we discuss our individual patient problems  through series of inputs from available global online community of experts with an aim yo solve those patients clinical problems with collective current  best evidence based inputs

 Date of admission : 06-09-2021

A 28yr old male resident of miryalguda , employee by occupation came to our hospital with complaints of weakness and decreased urine output on 19-06-2021 and got diagnosed as AKI .

History of present illness:

Patient was asymptomatic till April this year 

Patient had history of weight loss(10kgs) since 1 and 1/2 month and decreased appetite and decreased urine output and generalized itching . So he visited global hospital where they diagnosed with renal failure and hypertension.

Four sessions of hemodialysis were done here on AKI

Later got readmitted on 06-07-21 on CKD on MHD. 10 sessions of hemodialysis were done.

Currently patient has no history of pedal edema ,SOB and decreased urine output.

HISTORY OF PAST ILLNESS 

Patient has no history of pedal edema and SOB.

Patient has known history of hypertension since 4months .

No history of any surgeries.

No history of diabetes,fever.

No history of blood transfusions.

PERSONAL HISTORY

Normal appetite 

Bowel regular

Micturition - normal 

Patient was occasional alcoholic and non- smoker.

FAMILY HISTORY

No history of Diabetes, hypertension 

No history of cancer.

No history of hereditary symptoms.

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative.

There are no signs of cyanosis, lymphadenopathy, clubbing,icterus.

Vitals 

Temperature: afebrile 

Pulse rate : 92bpm

B.p : 140/90

Respiratory rate : normal

SYSTEMIC EXAMINATION 

Cardiovascular system

Thrills : No 

Cardiac sounds : S1 and S2 heard 

RESPIRATORY SYSTEM 

No dyspnea

No wheezing

Position of trachea : central

Breath sounds: vesicular 

Adventitious sounds - no 

ABDOMEN 

Abdomen distended,soft and non tender 

Bowel sounds heard 

Palpable mass - no 

Free fluid - no 

CENTRAL NERVOUS SYSTEM

Patient is conscious

Speech : normal 

no signs of meningeal irritation

Sensory and motor reflexes- intact 

PROVISIONAL DIAGNOSIS

CKD on MHD 

Known case of hypertension 

INVESTIGATIONS 

TREATMENT

T. LASIX 20mg/PO/BD 

T. NICARDIA -RETARD 20mg/PO/BD 

T. NODOSIS 500mg/PO/TID

T. OROFER - XT/PO/BD 

T.SHELCAL 500mg/PO/OD 

T.ALPHA D3 0.25mg/PO/OD 

INJ. ERYTHROPOIETIN -4000IU 

S/C WEEKLY ONCE