General medicine case on Renal Failure on 1/6/23

General medicine 
1st June 2023.
Name:M.Yashwitha 
Roll.no:73

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. This Elog reflects my patient centered online learning portfolio.

 Case on chronic Renal failure

 A male Patient aged 56 years brought to casuality with complaints of shortness of breath since yesterday night .

History of presenting illness :
• patient was apparently asymptomatic 2 months back, then he developed pedal edema ,decreased urinary out put and taken to private hospital and treated .
• pedal edema initially unilateral Right sided pitting type and then Bilateral with no pain, no itching and redness.
•patient developed low grade fever which is continuous without chills and rigor .
•Burning micturition is present .
•No history of pain abdomen, palpitations,vomitings .
•History of hypertension since 3 years and on medication TAB ATENOLOL and using TELMA for 1month .
•No history of diabetes mellitus,TB, epilepsy,Asthma,CAD.

General examination:

Patient was conscious, coherent, and cooperative.
* No signs of pallor,Icterus, clubbing,lymphadenopathy.
*Pedal edema :bilateral .
*Temperature:99°F
*Pulse rate:85 bpm.
*RR:16 Cpm
*Blood pressure:110/70 mmHg
*spo2:

Systemic examination:

*CVS: ~cardiac sounds - S1S2+
             ~no cardiac murmers .
*Respiratory system:
  -dyspnoea:no
  -wheeze:no
  -position of trachea:central 
 - breath sounds: vesicular .

*Abdomen:
-soft, non tender.
-shape of abdomen:scaphoid.
-palpable mass,free fluid :no
-liver:palpable.
-spleen:non palpable 
-bowel sounds:normal.

*CNS:
-no abnormality detected 

*Reflexes:
             Biceps.  Triceps. Knee. Ankle.
•Right:         +.          +.           +.        +
•left:             +.          +.           +.        +
•plantars:flexion

*Gait:normal.

Provisional diagnosis:
Acute on chronic renal failure ,glomerulonephritis?urosepsis with hypertension for 3 years.


Investigations:

∆ hemogram:
 -HB:10.3
-TLC:9000
-platelets: 2.10 lakhs 
-TBC: 3.93.

∆ RFT: on 30/5/23
-urea:164 mg/dl
-creatinine:6.9mg/dl
-uric acid :4.7mg/dl
-calcium:10.0mg/dl
-phosphorous:6.3mg/dl
-sodium:138meq/l
-potassium:3.4 meq/l
-chloride:101meq/l

∆HbsAg: negative.
∆Anti HCV Antibodies:non reactive
∆ LFT:
-total bilirubin:0.51mg/dl
-direct bilirubin:
-SGOT ( AST):15 IU/L
-SGPT( ALT):12 IU/L
-Alkaline phosphate:150 IU/L
-Total proteins:6.9mg/dl.
-Albumin:3.71 gm/dl

∆ Complete urine examination:
-colour: pale yellow
-Appearance: clear
-Reaction:acidic
-Specific gravity:1.010
-Albumin:++
-Sugar: nil
-bile salts: nil
-bile pigments:nil
-pus cells:4-5
-epithelial cells: 2-4
-red blood cells:6-8
-crystals: nil
-casts:nil
-Amphorous deposits: absent.

31/5/23
∆RFT:
-urea:154mg/dl
-creatinine:5.3 mg/dl
-uric acid:6.8mg/dl
-calcium:10 mg/dl
-phosphorous:5.4mg/dl
-sodium:137 meq/l
-potassium:3.1meq/l
-chloride:98meq/l

∆USG Abdomen:



∆ECG:

Treatment:
•salt restriction <2g/day.
•fluid restriction 1.5L/ day 
•Tab.NICARDIA 10 mg  PO/OD
•TAB.DOLO 650mg  PO/OD 
•TAB.SHELCAL 500 mg PO/OD
•TAB OROFER  PO/OD
•TAB.NODOSIS 500 PO/BD
•TAB BIO D3 PO/BD
•Inj.NEOMOL 1g IV sos
•Syp.CITRALKA 15ml PO/BD


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