GENERAL MEDICINE CASE DISCUSSION

MEDICINE CASE DISCUSSION

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    Adla Greeshma 

    Roll no: 148 

    3rd semester

CASE PRESENTATION 

  A 61 year male farmer by occupation came to OPD  for hemodialys.

COMPLAINTS AND DURATION 

 Patient was apparently alright 3 years back with complaints of lower back pain went to local hospital found out to be having RENAL FAILURE , on medication for 2 years ( with baseline serum creatinine 3mg/dl) 

Then went to NIMS hospital on 08/09/2020 with complaints of anorexia , dyspepsia , insomnia found out to be having serum creatinine 2mg/dl, Dialysis was initiated and on MHD weekly twice 

  HISTORY OF PRESENT ILLNESS :

On hemodialysis through radial AV fistula for 9 months.

Failed after 9 months

Tried Brachial AV fistula got failed 

Now getting dialysis through right femoral line on 16/10/2020

 HISTORY OF PAST ILLNESS:

k/c/o HTN since 3 years on irregular medication

 PERSONAL HISTORY :

married

Appetite - normal

Diet- mixed

Bowels- regular

Micturition- normal

 FAMILY HISTORY :

not significant

 GENERAL EXAMINATION:

Patient is conscious coherent and cooperative.

He is well oriented to time, place and person.

He is moderately built and well nourished.

  VITALS :

Temp - 98.4 F

Pulse rate - 84 beats/ min

Respiration rate - 24 cycles/ min

BP - 130/70 mm Hg

SpO2- 98%

 SYSTEMIC EXAMINATION:

A) CVS

    S1 and S2 are heard

    No cardiac murmurs

    No thrills found 

B) RESPIRATORY SYSTEM

     No dyspnoea 

     No wheezing

     Position of trachea is central

     Breath sounds vesicular

C) ABDOMEN

     Shape - scaphoid

     Liver and spleen non palpable

     Bowel sounds are heard

D) CNS 

      Normal

PROVISIONAL DIAGNOSIS

      CKD on MHD

       K/c/o HTN since 3 years 

       Dialysis started on 09/09/2020

INVESTIGATIONS:

  

FINAL DIAGNOSIS

    CKD on MHD

TREATMENT :

   1)fluid restriction < 1.5 lt/day

   2)Salt restriction  < 2gm/day

   3)Tab. LASIX 40mg × Po × BD

                    8am-4pm-×

   4)Tab. NODOSIS  500mg × Po × BD

                    8am-×-8pm

   5)Tab.BIO-P3  0.25 × Po × OD

                           ×-1-×

   6)Tab. SHELLAL CT 500mg × Po ×OD

                            ×- 1-x

    7) Inj. Erythropoietin 4000 IU s/c           weekly once