GM Case 03

 General Medicine Case 03

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 input.

A 60 year old female who used to work as a daily labour presently staying in home came with the chief complaint of fever, vomiting after eating , decreased urine output, pedal edema.

History of Present illness:-

Fever since 3 days back and got subsided,loose stools since 3 days back and got subsided.

Pedal edema on and off, decreased urine output since 3 days, drowsiness since 2 days.

Generalised weakness since 10 days. Vomiting after eating.

Shortness of breath, Facial puffiness since 2 days. 

Past History:-

Patient have Hypertension since 20 years.

No history of Diabetes, Epilepsy, Tuberculosis,Asthma.

Patient tends to have SOB after walking since 10 months.

Patient had Hysterectomy 2 years back ( has she had white discharge and pain).

Personal History:-

- Sleep is abnormal.

- Appetite is lost.

- Mixed diet.

- Bladder and bowel movements normal.

- No addictions.

Family History:-

- There are no similar complaints in the family members.

Treatment History:-

- She is not a known case of any drug allergy.

General examination:-

- Patient was conscious and cooperative.

- Patient shows generalised weakness.

- No Pallor , no cyanosis, no icterus, no generalised lymphadenopathy.

- Pedal Edema is present.


 Vitals:-
Temperature- afebrile
Pulse rate- 98 per min
Respiratory rate- 22 per min
Blood pressure- 120/90 mmHg

Systemic Examination:- 
CVS -- Cardic sounds s1, s2 
            No Cardiac murmurs

Respiratory system --- No Dyspnoea
                                        No wheezing sound 
                                Position of trachea is central

CNS ---- Patient is conscious
              Speech is normal
              Reflexes are normal
 
Abdomen--- abdomen is not tender
                   bowel sounds heard   
                   no palpable mass or free fluid

Investigations:- 











Final diagnosis:-
AKI ON CKD
 
Treatment:-
- Inj. Lasik 40 mg IV BD
- Inj.ZOFER 4 mg IV
- Inj. NaHCo3 50 M eq IV
- Tab Nodosis 500mg BD
- Tab.Shelcal CT OD
- Tab.Orofer XT BD
-Tab. Met XL 50 mg OD
- Tab. Ecospirin - AV OD
- Inj. Erythropoietin 4000 IU weekly once.

 --- Does CKD effects on GIT , If it is then how?
----- Does hysterectomy have effects on kidney? 
              

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