general medicine (5)

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 inputs. 



A 60 year old male came to OPD with the complaint of SOB, bilateral pedal, and decreased urine output since ten days.

October 28,2022

Chief complaint:
A 60 year old male came to OPD with the complaint of SOB, bilateral pedal, and decreased urine output since ten days.

History of present illness: patient was apparently asymptomatic ten days back then later he noticed sob(grade 2 and grade 3)with aggravating and relieving factors
-decreased urine output

History of past Illness:
- no complaints of burning during micturition
-k/c/o- htn since 10 years
-n/k/c/o- asthma, epilepsy,cad,tb
Treatment history: 
-no dm
- htn present
-no cad
-no asthma
-no known relevant drug history
-no chemotherapy, radiation ,blood transfusions done.
Personal history:
Married
Appetite normal
Occupation: farmer
Mixed diet
Bowel and bladder: regular
No known relevant allergies
No addictions
Family history:
No other family member has similar complaint
Physical examination:
General examination: -no pallor
                           -no lymphadenopathy 
                                     -no icterus
                                   -no cyanosis
                         -edema of the feet is seen
Vitals:
Temp: 97°f
Pulse rate: 98/min
Respiratory rate: 22/min
Systemic examination: 
Cvs: -no thrills
       - nocardiac murmurs
Respiratory system: - no dyspnea
                                     -No wheeze
                       - Breath sounds- vesicular
                        
                     -position of trachea-central 
Abdomen: shape of the abdomen: scaphoid
- no tenderness
- no palpable mass
- hernial orifice normal
-no free fluid
- spleen and liver: not palpable
CNS: level of consciousness - conscious
     - Speech : normal
- No neck stiffness and no kernings sign
Provisional diagnosis:
Ckd on mhd.
Plan of care: hemodialysis
Investigations:

Treatment:
 Tab: lasix 40 mg
          Orofer
       Shelcal 500 mg
       Bio p3

Inj: erythropoietin 4000iu weekly once
 

 

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