CKD CASE -Laxamma

CASE SCENARIO
A 90yr old female came to the Casuality with Chief complaints of Fever since 7 days

HISTORY OF PRESENTING ILLNESS:-
Patient was apparently asymptomatic 10 days back but then she had bilateral pedal edema pitting type with fever and chills  intermittent and no evening rise in temperature she also had decreased urine output and decreased appetite since 10 days she has vomiting 3episodes 5 days back  which was non bilious and non projectile containing food particles resolved after taking medication

CHIEF COMPLAINTS -
    Fever -10 days
    Decreased appetite - 10 days 
    B/L pedal edema - 10 days
     Decreased urine output -10 days  
    Vomiting- 5 days back

PAST HISTORY:-                                                            
  No C/O - chest pain
  H/O- Hypertension - 2yrs on medication
                                               
Not a K/c/o Asthma,Epilepsy,Tb

TREATMENT HISTORY:-
Tab.Amlodipine5mg
            +
Tab.Atenolol50mg
PERSONAL HISTORY



 Married

Occupation - farmer

decreased appetite

Bowel - regular

Micturition- decreased

 No ADDICTIONS-

No addictions


FAMILY HISTORY

Diabetes - No

Asthma - No

Hypertension - yes

Heart disease - No

Stroke - No

Cancer -No

No palpable mass

Bowel sounds- present

GENERAL EXAMINATIONS

 No-

Icterus/Cyanosis/Lymphadenopathy/Malnutrition

Temperature -100F

Pulse rate - 82beats /min

Bp - 140/90mmhg

SpO2 - 96%

GRBS - 160mg%

SYSTEMIC EXAMINATION

CVS:  

No Thrills
Cardiac Sounds - S1, S2 +

No cardiac murmurs
RESPIRATORY SYSTEM: 
Dyspnoea - No

No Wheezing

Position of Trachea - central

Vesicular sounds 

ABDOMEN:



Shape - Scaphoid

No palpable mass

Bowel sounds- present

CNS:

Level of consciousness - conscious

Glassgow scale -E4 V5 M6
GAIT, MUSCULO SKELETAL SYSTEM, SKIN, ENT, HEAD AND NECK - NORMAL 

PUSTULAR LESIONS SEEN IN ORAL CAVITY

PRESENT ON HARD PALATE AND OROPHARYNX

 INVESTIGATIONS:-
Hemogram,Renal function test,ECG,USG abdomen,chest x-ray.

Hb:6.1

PCV:19.2

TLC:9,400

RBC: 2.08

Platelet count:2.69

Blood urea: 2.14

Serum creatinine :10.0

S.Na+:126

S.K+:5.8

S.Cl-:89

PROVISIONAL DIAGNOSIS

Chronic renal failure 
ULTRA SOUND
TREATMENT:-
IV fluid 20 ns IV/BOLUS

IVF 0.9% NS 100ml/hr

Inj.pan 40 mg IV/STAT

Inj. LASIX mg IV/STAT

Inj zofer 4mg IV/STAT








Comments

Post a Comment

Popular posts from this blog

OSCE PRRFINAL

OSCE QUESTION:- How will the ventilator helps a pneumonia patient ? -Helps in opening alveoli  -Ventilators help pneumonia patients by providing support to their breathing.  -They deliver oxygen and help remove carbon dioxide from their lungs.  -It helps them breathe easier and allows their body to focus on fighting the infection. LEARNING POINTS:- 1) Once again got an opportunity to understand the art of case taking.  2) How to communicate with a geriatric age group patient. 3) Importance of adequate dose of drug administration ( MIDAZOLAM in this case) and effects of prescribing underdosage of midazolam 4) MIDAZOLAM - effect, adverse effects, therapeutic window.
Read more

83 Year old male with Pneumonia

Image
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 83yr old male came with complaints of  shortness of breath since 10 days. chief  complaints:  cough since 16 days Fever since 14 days shortness of breath since 12 days History of Presenting illness: Patient was admitted to ICU 16 days back with  breathlessness. It was insidious in onset and g
Read more