1601006147 LONG CASE

1601006147 LONG CASE

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 


Naga Vamsi


Hall ticket no 1601006147


Date 24 April 2021




A 65 year old female patient resident of mirlayaguda home resident present to the opd with


chief complaints of:


Vomiting 4 days back and malaise

History of present illness 


Patient was apparently a symptomatic 4 days ago before the episode of vomiting then had vomiting which was not blood stained not associated with pain and bilious in nature 


The episode was later followed by lack of appetite and patient stopped diabetic medication(insulin)


Past history 


The patient is know case do diabetes mellitus diagnosed 14 years back on insulin 


The patient was diagnosed with hypertension 1 year back


She was previously diagnosed to have kidney disease


No history of tb asthma heart disease epilepsy


No relevant surgical history


No significant family history


Personal history


Decreased appetite 


Mixed diet


Bowel and bladder movements irregular 


Patient has oliguria


No smoking or alcohol


General examination 


Patient was conscious coherent and cooperative moderately built and nourished


Pallor is present 


No jaundice no cyanosis no clubbing no pedal Edema h/o occasional facial puffiness which resolves spontaneously no lymphadenopathy 


Vitals 


Pulse checked in supine position left radial pulse pulse rate is 80 regularly regular


Bp 130\80 mm Hg measured in supine position on left arm


Respiratory rate 18 cycles per minute


Afebrile


The patient examined in supine position in well lighted and ventilated room after taking consent

The patient abdomen inspected no abdomen distension or fullness skin was normal no distended veins


On palpating no tenderness rigidity or guarding no local rise of temperature or any swellings


Percussion for organomegaly was done and auscultation for bowel was done


Cvs examination 


S1 and s2 was heard

No murmurs no palpable thrills


Cns examination 


Conscious and alert 

Normal speech

Glasgow coma scale normal


Respiratory examination 


Shape is normal

Symmetrical chest 


Movement of chest normal respiratory rate 18 cpm equal movement on both side

No involvement of aces out muscles no inter coastal retraction

No scar no sinuses or distended veins no deformity of spine no visible apical impulse

Palpation

No rise in temperature on palpation

Inspectors findings confirmed

Trial sign negative Trachea central

Apex beat felt in 5 the intercostal space lateral to midclavicular line percussion is resonant normal vesicular breath sounds




Investigation 

⁃ CBP


⁃ CUE


⁃ Abg 



⁃ RFT 



⁃ LFT



⁃ PT


⁃ APTT


⁃ Blood sug ar 


   

⁃ ESR  


⁃ Serum pottasium 


⁃ Blood culture 


⁃ Chest x ray 


⁃ Ecg 


⁃ Ultrasound abdomen 



⁃ Hrct




 DIAGNOSIS : chronic renal failure or acute exacerbation of chronic renal failure


TREATMENT 

⁃ Salt and fluid restriction 

        Salt - < 2 g/ day 

        Fluid - < 1 lt / day 

⁃ Injection  iv LASIX 40mg BD 

⁃ Tab NODOSIS  500mg bd 

⁃ Tab SHELCAL 500mg od

⁃ Input and output charting 

⁃ Bp  pulse  spo2 charting 

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