General medicine

B.Varshitha 
5th semester 
Roll no.21

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

A CASE OF CHRONIC KIDNEY FAILURE 

A 62years old male patient came to the hospital with cheif complaints of nausea,loss of appetite, bilateral pedal edema since 1week.

History of present illness 
Patient was apparently asymptomatic 4years back then he developed weakness and pain in both lower limbs.

Past history 
Known case oh hypertension 
Not a known case of diabetes, TB, epilepsy,CAD,asthma

Personal history 
Appetite: lost
Diet : non-vegetarian 
Bowel habits : irregular 
Bladder habits : decreased urine output
Regular alcohol consumer 
Smoker 

Family history 
No history of HTN,TB,epilepsy,asthma,CAD

General examination 

Physical examination 
No pallor
No icterus
No cyanosis
No lymphadenopathy
No clubbing of fingers
Moderately built and moderately nourished.
Bilateral pedal odema

Vitals
Temperature: afebrile
Pulse rate:80/min
BP:140/70
RR:20/min
SPO2:96%

SYSTEMIC EXAMINATION

CVS

S1,S2 Heard
No murmurs

RESPIRATORY SYSTEM

Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular

ABDOMEN

No tenderness
No palpable mass
No briuts
No palpable spleen and liver
Bowel sounds-yes

CNS

Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness.
Sensory system- Normal
Motor system- normal

INVESTIGATIONS

-hemogram,LFT,RFT,CUE,CXR,ECG
2D-ECHO,USG Abdomen, serology.

Hemogram 


LFT

RFT
CUE
2D-ECHO 
Blood urea
Serum creatinine
Serum electrolytes

Anti HCV antibodies 
HBsAg-Rapid
ABG
Random Blood sugar 








Treatment 

12/06/2022

TAB. LASIX 40MG twice a day
TAB. PAN 40MG once a day before food
TAB. NODOSIS 500MG twice a day
TAB. SHELCAL 500MG once a day
TAB. MVT once a day
SALT AND FLUID RESTRICTION 
BP/PR/TEMP 4TH HOURLY
GRBS-12TH HOURLY


13/06/2022

TAB. LASIX 40MG twice a day
TAB. PAN 40MG once a day before food
TAB. NODOSIS 500MG twice a day
TAB. SHELCAL 500MG once a day
TAB. MVT once a day
SALT AND FLUID RESTRICTION 
BP/PR/TEMP 4TH HOURLY
GRBS-12TH HOURLY
IVF-U.U+30ML/HR

14/06/2022
IV FLUIDS  NS@VO+30ML/HR
TAB. LASIX 40MG twice a day
TAB. NODOSIS 500MG twice a day
TAB. SHELCAL 500MG once a day
TAB. MVT once a day
SALT AND FLUID RESTRICTION 
BP/PR/TEMP 4TH HOURLY
GRBS-12TH HOURLY



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