General medicine case-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.

Date of admission:12-09-21


A 70 year old female came with a chief complaint of pain in the stomach since 15 days.


History of present illness:

The patient was apparently asymptomatic 2 months back then developed shortness of breath. And pain in the stomach since 15 days.

She also experienced 4-5 episodes of loose stools 3 days back which then subsided.

4 days back the patient had high grade fever which subsided.

The patient is currently undergoing dialysis since 1 week.


History of past illness:

The patient is a known case of hypertension since 20 years and is on medication.

She is not a known case of diabetes, epilepsy, tuberculosis, asthma.

The patient underwent hysterectomy 4 years back.



Personal history:

The patient has normal appetite.

Has mixed diet.

Has adequate sleep.

Bowel movements are normal.

Decreased urine output since 3 days.

The patient has a habit of chewing betel leaf.


Family history:

There are no similar complaints in the family.


Treatment history: 

The patient is not allergic to any known drugs.


General examination:

Patient is conscious, coherent, cooperative at the time of joining.

- Pallor is present.

- No icterus present 

- No cyanosis present.

- No clubbing of fingers and toes.

- No lymphadenopathy.

-No pedal edema.



Vitals: 

Temperature: afebrile.

Pulse rate: 98 bpm.

Respiratory rate: 22 cycles per min.

BP: 120/90 mm/Hg


Systemic examination : 

CVS

Inspection - chest wall is bilaterally symmetric

- No precordial bulge

- No visible pulsations, engorged veins, scars, sinus

Palpation - JVP is normal

Auscultation - S1 and S2 heard.


RESPIRATORY SYSTEM

- Position of trachea is central

- Bilateral air entry us normal

- Normal vesicular breath sounds heard

- No added sounds


PER ABDOMEN

- abdomen is tender

- bowel sounds heard

- no palpable mass or free fluid


CNS

- Patient is conscious

- Speech is present

- Reflexes are normal.


Investigations:












Diagnosis:

Chronic kidney disease

Treatment:

1) Inj. CEFTRIAXONE 1mg/IV/BD

2) Inj. LASIX 40 mg IV/BD

3) Inj. ZOFER 4mg IV/SOS

 4) Inj. NODOSIS 500 mg PO/BD

5) TAB SHELLAL CT PO/OD

6) TAB LIVOGEN PO/BD

7) TAB MEXTL 50 mg PO/OD

 8) TAB ECOSPRIN-AV PO/OD/HS

9) Inj. ERYTHROPOIETIN 4000 IU/SC weekly



1) What other complications does hypertensive patients with CKD may have?

2) Do habits such as betel leaf chewing affect kidney function?


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