48 years old male with CHRONIC RENAL FAILURE

48 YEARS OLD MALE WITH CHRONIC RENAL FAILURE 

NOVEMBER 9TH 2022

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 inputs. 


This Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment

CHIEF COMPLAINTS 

Bilateral Pedal Edema since 1 month
Shortness of breath  since  1 day
Vomitings since 1 day

History of presenting illness

Patient was apparently asymptomatic One month back then he developed Bilateral Pedal Edema which was insidious in onset ,gradually progressive, pitting type extending from ankle.

Patient also complained of shortness of breath, insidious in onset, gradually progressive, aggrevated by work and relieved on rest.

Patient had history of vomitings since 1 day with Food as contents,non projectile, non bilious.
Patient also had decreased urine output.

HISTORY OF PAST ILLNESS 

No similar complaints in the past 
Patient had history of tuberculosis and was on ATT therapy for 3 months
Known case of HYPERTENSION since 5 years and is on medication 

Not a known case of Epilepsy and coronary artery disease 

Patient had previous history of RTA and underwent surgery of right leg.

 FAMILY HISTORY 
 
Not significant 
 
PERSONAL HISTORY 

Appetite is reduced 
Diet is mixed
Bowel and Bladder movements Regular 
Sleep Adequate 
No Addictions 
Drinks alcohol occasionally 

GENERAL EXAMINATION:
Patient is conscious coherent and cooperative 
Pallor-present
Icterus-mild Icterus is present
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Pedal edema-present(pitting type)
VITALS:
Temperature-98.4
Pulse rate-84beats per minute 
Respiratory rate-16 breaths per minute 
Blood pressure-140/90mm hg
SpO2-98 at room air

SYSTEMIC EXAMINATION 
Cardiovascular system-S1 and S2 heard ,no murmurs heard

Respiratory system:
No dyspnoea 
Breath sounds-vesicular breath sounds are normal

Central nervous system:
Patient was conscious,coherent and cooperative.
Speech was normal
No slurred speech
No Meningeal irritation signs
-No abnormality detected. 
Reflexes are normal

 Abdomen is soft and non tender


                                             INVESTIGATIONS 
HAEMOGRAM
 
RENAL function test
Liver function test
Serum iron
Random blood sugar 
HBs Ag Rapid
 HIV 1/2 RAPID TEST

Anti HCV ANTIBODIES RAPID

PROVISIONAL DIAGNOSIS 
CHRONIC RENAL FAILURE 

TREATMENT:
T.LASIX 40 mg PO OD
T.NICARDIA 1O mg PO OD
T.NODOSIS 500mg PO OD
T.OROFER PO OD
T.SHELAL PO OD
INJ.HAI S/C acc to GRBS
Syp.ASCORIL  PO TID 15ml
Vitals monitoring 4th hourly






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