1601006119- SHORT CASE

This is an online e logbook to discuss our patients deidentified health data shared after his guardian s informed consent .

A 45 yr old male patient resident of Nalgonda, labourer by occupation came with cheif complaints : 

.Pedal edema since 10 days

. Decreased urine output since 5 days

.  Fever since  5 days

History of presenting illness :

Patient was apparently asymptotic 10 days ago .then  he developed ,

- bilateral pedal edema.                                              Which is insidious in onset , gradually progressive, which is pitting type

 - history of burning micturition

- fever not associated with chills & rigors

- no history of sweating, chestpain  ,hematuria

Past history :.                                                             he had  kidney issues  6 months back, for that he took medication.                  He had TB in the past 1 yr , that is cured

- not a known case of diabetes, hypertension , asthma ,convulsions

family history - not significant

Personal history :

Diet - mixed.                                                      Decreased  appetite.                                      Bowel habits are normal. 

Pt with oliguria, burning micturition

Addictions : alcoholic since 10 yrs

                      Smoking since 10 yrs

General examination :.                                              patient is concious, co operative, moderately built , moderately nourished.       Pallor  present,No icterus, no cyanosis, no clubbing, no lymphadenopathy

- pedal edema present

Vitals  :

Pulse rate- 80 bpm

BP- 130/80 mmHg

RR -20 cpm

Afebrile

SYSTEMIC EXAMINATION :

Respiratory system : 

Inspection - shape & symmetry of chest normal

  No visible scars, no sinuses, no engorged veins     

Palpation : vocal fremitus decreased at infraclavicular, intramammary area

On percussion : dull note seen on    infrascapular area on both sides

Auscultation :

- bilateral air entry present

- normal vesicular breath sounds heard

- fine crepts heard on bilateral infra axillary & infraspinatus areas

CVS :

S1 & S2 heard , no murmurs, no thrills

ABDOMINAL EXAMINATION :

 Scaphoid shape

No tenderness

No organomegaly

No ascites

Bowel sounds present

CNS : pt concious alert, normal gait, no signs of meningeal irritation, cranial nerves intact, 

INVESTIGATION S :

. CBP , CUE , RFT, LFT, Blood sugar ,ESR , serum potassium ,  blood culture , chest X ray , 

 Treatment :

Salt and fluid restriction

- injection IV lasix 40 mg bid

- Tab NODOSIS 500 mg

- Tab SHELCAL 500 mg od

- BuDicort

Provisional diagnosis :

Acute on chronic renal failure with bilateral pleural effusion