63year old male with shortness of breath.
April 18th 2022
18/04/22
-SEROLOGY : NEGATIVE.
-THERAPEUTIC PARACENTESIS DONE.
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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.
A 63year old male patient farmer by occupation brought to casualty with c/o : SOB(grade - lll) since 1month, generalised weakness since 1month, facial puffiness a/w itching since 1month.
HOPI : Patient was apparently asymptomatic 1month back, then he gradually developed SOB(grade- lll) which increased on exertion, facial puffiness, itching, generalised body edema.
PAST HISTORY : Patient is a k/c/o HTN since 3years and is on tab nicardia 20mg
-No h/o DM, tb, epilepsy, cad, asthma.
-H/O renal calculus in left kidney 2years back for which he underwent surgery.
-H/O fracture of forearm 5 yrs back.
PERSONAL HISTORY : Diet - mixed, Sleep - adequate, Appetite - normal, Bowel and bladder movements - normal.
GENERAL EXAMINATION :
Patient is conscious, coherent, cooperative
well oriented to time and place.
No pallor, icterus, cyanosis, lymphadenopathy.
VITALS:
Temp- 98.6F
PR - 92bpm
Spo2 - 99%
RR - 16cpm
GRBS - 110mg/dl
Blood Pressure - 110/80mmhg
CVS - S1,S2+ no murmurs
RS - BAE+, nvbs heard
no wheeze, no crepts
P/A - Soft, non tender, organomegaly
Bowel sounds +
CNS - NFND
INVESTIGATIONS-
19/04/22
23/4/22
Urology referral done :
As Left side kidney is shrunken ,doing a right nephrectomy will not do anything benefecial and the patient is not actively having any pain on right loin or fever due to pyelonephritis.So adviced for maintenance hemodialysis.
PROVISIONAL DIAGNOSIS :
Post Renal AKI(ON CKD) with RIGHT HUN WITH GROSS ASCITES.
TREATMENT :
1) FLUID AND SALT RESTRICTIOB
2)TAB NICARDIA 20MG PO/BD
3)TAB NODOSIS 500 PO/BD
4)TAB OROFER- XT PO/BD
5)CAP BIO- D3 PO/BD
6)INJ ERYTHROPOIETIN 5000 IU/SC/WEEKLY ONCE
7)TAB SHELCAL 500MG PO/BD.
