Case history 3

 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 is a case of 38 year old male patient a daily labour by occupation presented to opd with chief complaint of decreased appatite from past four months and fever since three months,it's raised since ten days, decreased urine output, nausea.

History of present illness :

Patient was asymptomatic five months back then he developed loss of appetite , reduced sleep and decreased urine output associated with fever.
No h/o Sob
No h/o facial puffiness 
No h/o chest pain 
No h/o palpitations
Patient is undergoing hemodialysis (2 times) 

Past history:

 There is no history of hypertension, diabetes mellitus , tuberculosis, asthma, and epilepsy,no h/o any surgeries.

Personal history: 

Diet: mixed.

Sleep : reduced

Bowel and bladder movements :Normal.

Appatite:loss of appetite

Micturition: decreased

Habits: Alcoholic and smoker.

Drug history:

There is no history of allergies to any known drugs.

Family history:

There is no history of similar complaints in family members.

General Examination:

The patient is conscious, coherant and cooperative. He is well oriented to time , place and person . Moderately built and nourished
Anemia present
Pallor present
No icterus
No cyanosis
No clubbing
No generalized lymphadenopathy. 

Vitals 
PR 90bpm
RR 17cpm
BP 110/70mmHg
SpO2 98% in room air
Temperature febrile.
 

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

Inspection: 

Chest wall is bilaterally symmetrical

No Precordial bulge

No visible pulsations, engorged veins,scars, sinuses

Palpation:

JVP - normal

Apex beat : felt in the left 5th intercostal space

In midclavicular line 

Ausculation:

S1 ,S2 Heard


RESPIRATORY SYSTEM

Bilateral airway +

Position of trachea- central

Normal vesicular breath sounds - heard

No added sounds


PER ABDOMEN

Abdomen is soft and non tender 

Bowel sounds heard

No palpable mass or free fluid 


CENTRAL NERVOUS SYSTEM

Patient is conscious 

Reflexes are normal 

Speech is normal.

Investigations:












Provisional diagnosis:

Acute kidney injury on CKD

Treatment plan:

Inj :Lasix 40 mg IV -OD
Tab Nudosis 500mg oral -OD 
Tab Shelcal oral-OD
Tab Orofer XT oral -BD
Inj Erythropoietin 4000 IV
Inj Iron sucrose 
Syrup Artstozyme 10 ml oral -TID.

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