GENERAL MEDICINE E-log

 NAME: A Sanvith

ROLL NO: 09

A CASE OF CHRONIC KIDNEY FAILURE

A 62years old male patient came to the hospital with cheif complaints of nausea,loss of appetite, bilateral pedal edema since 1week.


History of present illness.

Patient was apparently asymptomatic 4years back then he developed weakness and pain in both lower limbs.

Past history

Known case oh hypertension 

Not a known case of diabetes, TB, epilepsy,CAD,asthma

Personal history

Appetite: lost

Diet : non-vegetarian 

Bowel habits : irregular 

Bladder habits : decreased urine output

Regular alcohol consumer 

Smoker 

Family History

No history of HTN,TB,epilepsy,asthma,CAD.

 GENERAL EXAMINATION

Physical examination.
No pallor
No icterus
No cyanosis
No lymphadenopathy
No clubbing of fingers
Moderately built and moderately nourished.
Bilateral pedal odema.

Vitals
BP:140/70
RR:20/min
Pulse rate:80/min
Temp: afebrile
SPO2:96%

SYSTEMIC EXAMINATION

CVS
S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN

No tenderness
No palpable mass
No briuts
No palpable spleen and liver
Bowel sounds-yes

CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness.
Sensory system- Normal
Motor system- normal

INVESTIGATIONS

-hemogram,LFT,RFT,CUE,CXR,ECG
2D-ECHO,USG Abdomen, serology.

















Provisional Diagnosis:
                      
CHRONIC KIDNEY DISEASE


Treatment 


12/06/2022


TAB. LASIX 40MG twice a day

TAB. PAN 40MG once a day before food

TAB. NODOSIS 500MG twice a day

TAB. SHELCAL 500MG once a day

TAB. MVT once a day

SALT AND FLUID RESTRICTION 

BP/PR/TEMP 4TH HOURLY

GRBS-12TH HOURLY



13/06/2022


TAB. LASIX 40MG twice a day

TAB. PAN 40MG once a day before food

TAB. NODOSIS 500MG twice a day

TAB. SHELCAL 500MG once a day

TAB. MVT once a day

SALT AND FLUID RESTRICTION 

BP/PR/TEMP 4TH HOURLY

GRBS-12TH HOURLY

IVF-U.U+30ML/HR


14/06/2022

IV FLUIDS  NS@VO+30ML/HR

TAB. LASIX 40MG twice a day

TAB. NODOSIS 500MG twice a day

TAB. SHELCAL 500MG once a day

TAB. MVT once a day

SALT AND FLUID RESTRICTION 

BP/PR/TEMP 4TH HOURLY

GRBS-12TH HOURLY





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