General medicine case history 1

74. S.Nithesh

GM Case history-1

August 10, 2021

 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.

  

Date of admission: 09-08-2021

A 56- year- old woman presented to the OPD with chief complaints of fever, decreased urine output since 3 months and breathlessness from the past 3 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 5 years back, then had fever which was insidious and associated with chills, vomiting and pain in the loin for which she went to outside hospital where she was diagnosed with kidney disease, from then she was on medication.

7 months back she stopped medication for 1 month, then after that she developed shortness of breath for which she went to a local hospital where she was referred to our hospital.

She was diagnosed to have chronic kidney disease and adviced to get hemodialysis done

From then on she was on hemodialysis twice weekly.

Now for the past 3 days she is complaining of high grade fever which was associated with chills and rigors and nausea , vomiting of 2 episodes non billions, non projectile, food as content

Not associated with pain abdomen or loose stools.

 

PAST HISTORY: 

K/c/o Hypertension since 6 years

Not a known case of CAD, Asthma,TB, Epilepsy, Thyroid disorders.

No history of sugeries and blood transfusions in the past.

PERSONAL HISTORY:

The patient is a vegetarian.

Appetite is decreased due to dialysis

Regular bowel and bladder movements

Normal sleep

No addictions

FAMILY HISTORY: 

There are similar complaints in the family( The patient's mother and sister had suffered from the similar condition).

No cancer deaths in the family.

TREATMENT HISTORY:

The patient is not allergic to any known drugs.

GENERAL EXAMINATION: 

On examination,the patient is conscious, coherent, co-operative.

No icterus and pedal edema.

The patient has pallor

No cyanosis, clubbing, edema, lymphadenopathy.

VITALS: 

Temperature-98⁰F

Pulse rate-118bpm

Respiratory rate-18 cpm

BP - 100/50 mm/Hg

SPO2 at room air-98%

GRBS- 127 mg/dl

SYSTEMIC EXAMINATION: 

CARDIOVASCULAR SYSTEM:

S1 and S2 sounds heard, no murmurs.

RESPIRATORY SYSTEM: 

Position of trachea- central

Dyspnoea- present

Normal vesicular breath sounds heard

No wheezing

No additional sounds heard.

PER ABDOMEN: 

Abdomen is soft and non tender.

Bowel sounds heard.

No palpable mass or free fluid.

CENTRAL NERVOUS SYSTEM: 

The patient is conscious

Speech: normal

No signs of meningeal irritation

Motor and sensory system: normal

Reflexes- present

Cranial nerves- intact.

INVESTIGATIONS:

09-08-2021: 

PROVISIONAL DIAGNOSIS:

Chronic kidney disease?

FINAL DIAGNOSIS:

Chronic kidney disease with k/c/o hypertension

TREATMENT :

 - Fluid (<2L/day) and salt restriction (<2gm/day)

 - TAB. LASIX 40mg PO BD

 - TAB. PCM 500mg PO

 - TAB. OROFER- XT PO OD

 - TAB. SHELCAL 500mg PO OD

 - TAB. NODOSIS 500 mg PO OD

 - TAB. NICARDIA 10mg PO BD 

 - BP and fever charting, inform SOS.

Archive

Report Abuse