Renal failure
Hello all this is G Jagadeesh,a fifth semester student.This E Log depicts the patient centered approach to learning.
This is an online E Logbook recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Date of admission : 4/7/22
A 65 year old male patient came to medical OPD with Chief complaints of
1) Generalised Swelling and
2) Decreased urine output Since 10 days
History of presenting illness
patient was apparently assymptomatic 4 years back and then developed pain abdomen. At that time he was diagnosed as having Renal calculi and underwent percutaneous Neprolithotomy in our hospital and later got discharged.Later he developed generalised weakness and dizziness for which he was diagnosed as having diabetes mellitus and Hypertension 2 years back.He was on irregular medication for this unresponsive behaviour he was in Icu for 4-5 days and diagnosed to be hypoglycemia 2years back and creatinine levels are 5. 94 for which they have done dialysis and dischargedPedal edema was present but no decrease in urine output Now he has decreased urine output for lday and anuria for 3 days taken to hospital.
History of past illness
He is a known case of diabetic since 2 years
known case of Hypertension since 2years
NO Similar complaints in past
NO h/0 TB, asthma,Seizures
Treatment history
He is on Diabetic and H TN therapy
Allergic history
No known allergies
Personal history
Diet : mixed type
Appetite: lost
Bowel movements:Normal
Micturition: Abnormal
sleep: Adequate
Addictions: occasional Alcohol consumption
smoking
Family history
No relavant family history.
GENERAL EXAMINATION
patient is Conscious coherent and cooperative and well oriented with time and place
He is well nourished and built
There are no sign of
Icterus
Cyanosis
clubbing
Lymphadenopathy
There is presence of
pallor: yes
oedema: yes
Temperature: 101 degree fahrenheit
pulse rate: 106 per min
Respiratory rate:22 per min
Blood pressure: 160 / 90 mm of Hg
SYSTEMIC EXAMINATION
CVS
S1, S2 are heard
NO murmurs
Respiratory system
Dyspnoea: Yes
No Wheeze
Abdomen
Obese and non tender
There is no free fluids
Liver and spleen are not palpable
Bowel sounds are normal
CNS
Conscious with normal speech
There are no sign of meningeal irritation
Glasgow scale 15/15
INVESTIGATIONS
RFT
HEMOGRAM
Random Blood glucose
142mg/dl
Fasting Blood glucose
101mg/dl
Ultrasound
Impression
Bilateral simple renal cortical Cysts
Right upper ureteric calculus
B ilateral moderate hydrouretero nephrosis
ECG
Diagnosis.
Chronic Renal Failure with DM and HTN
TREATMENT
Salt restriction
Water restriction
Inj Lasix 40mg IV/bd
Tab. Nicardia 10 mg Bd
T. Nodosis 500mg Bd
T. Shelcal 500mg OD
T. Orofer OD
Ing. E poeitin 4000 IU Sc Weekly twice
plan Hemodialysis
on 5/7/22
BP: 100/70 mm of Hg
PR:77 bpm
RS: 18 Cpm
CVS : SI and S2 Normal
CNS: NAD
per abdomen: soft and non tender
6/7/22
BP:90/60 Mm Hg
PR:86 bpm
C VS:SI,S2 +
C NS :NAD
per abdomen:softand non tender
Treatment
Inj Lasix40mg IV Bd
Tab. Nicardia
T. Nodosis
T. Shelcal
T. Orofor
T. Dolo
7/7 / 22
BP:110/60 mm Hg
PR:80 bpm
C V S :SI,S2 +
CN S:NAD
per abdomen:soft and nontender
Treatment
Inj Lasix
Tab. Nicardia
T. Nodosis
T. Shelcal
T. Orofer
T.Dolo
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