General medicine case 8

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

A 65 year old male patient , daily wage worker by occupation came to opd with chief complaints of  swelling in his legs 1 week back and shortness of breath since 3 days.

History of Present Illness :

Patient was apparently asymptomatic 4 months back then he developed fever for which he went to RMP doctor and took medication for that . 

As fever didnt subsided then he went to Nalgonda for same reason where he was told that he was having some kidney problem.  As patient was not willing to admit he was under medication for that . 

1 week back he had developed bilateral pedal edema and 3 days back he was having shortness of breath and neck pain due to which he was admitted in hospital after doing some tests .

Daily routine : 

Before  : 

 He wakes early in the morning at 6:00am. At 8 am he have his breakfast. At 9 am he used to go to his work place . By 1 pm he have his lunch.  At 6 pm he used to go home . At 7 pm  he used to drink alcohol . By 8 pm he have his dinner . He goes to sleep by 9 pm . 

Due to his old age he was not going to work since 1 year . 

After : 

He wakes up at 6 am ,have his breakfast at 9 am , after having his breakfast he stays at home watch tv .... at 1 pm he used to have his lunch . At 8 pm he have his dinner . Around 9pm he used to sleep .

No alcohol intake since 4 months

Past history : 

Hypertension since 2 years 

No history of diabetes  , Tuberculosis, epilepsy , thyroid , asthma 

No surgeries in the past . 

Personal history: 

Diet : mixed 

Sleep : adequate 

Apetite : Lost 

Bowel and bladder movements : Normal 

No burning micturtion 

Habits : chronic alcoholic since 20 years 

Smoking : 18 BDs daily since 20 years 

Family history: 

No similar history in the family 

General examination: 

Patient is conscious , coherent and well built 

Pallor - Yes 

Cyanosis - No 

Icterus - No 

Lymphadenopathy - No 

Vitals: 

Temperature: Afebrile 

Pulse rate : 99 beats/ min 

Respiration rate : 18cycles / min 

BP : 160 / 90 mmhg 

GRBS : 115mg% 






Systemic Examination :

CVS : S1 S2 HEARD , no cardiac murmurs 

Respiratory system : 

Dysponea : Yes 

Position of trachea : central 

Abdomen : 

Shape : Scaphoid 

Liver and spleen not palpable 

CNS : 

Conscious 

Speech - Normal 

Investigations: 










Provisonal diagnosis: 

Chronic renal failure with metabolic acidosis 

Treatment:

Salt restriction <2.4gm / day 

Fluid restriction : <1 lt / day 

Tab .Lasix 40mg /Po/Tid 

Tab. Nodosis 550mg / Po/ bd 

Tab. Orofer Xt / Po / Od 

Tab. Shelcal 500mg / Po /Od 

Inj. Erythropoitein 4000 IU /S/C weekly once 




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