66 KVN Sudheer kumar

GENERAL MEDICINE ELOG

Chief complaints :

A 50 yrs old male came with cheif complaints of

*History of decreased urine output since 10 days.
* Bilateral pedal edema since 10 days.
* Shortness of breath since 10 days .

History of present illness:

* patient was apparently asymptomatic 10 days back.
* Then he developed decreased urine output and shortness of breath.
* History of pedal edema which is pitting type.

History of past illness:

* Hypertension since 2 years
* Diabetic since 3 yrs ( DM )- With irregular medications

Personal history:
*Martial status: married
*Appetite normal
*Non vegetarian
*Bowel: regular
*Decreased micturation
*No allergies
*Daily alcohol consumption

Family history:

* Not significant

General Examination:

Patient is conscious, coherent,cooperative
Moderately built and well nourished
*Patient is pallor
*No cyanosis 
*No lymphadenopathy
*No dehydration
*No malnitrition
*Edema of feet is present
*No icterus
*No clubbing of fingers and toes

No abnormality detected in genitals, Speculum examinations, PV examinations and P/R examinations.

Vitals:

Temperature: 98° F
Pulse rate: 98 beats/minute
Respiratory rate: 22/minute
Blood pressure: 140/80 mg
SpO2 : 95%
GRBS :142 mg%

Systemic Examination :

CVS

*No thrills
*No murmurs
*S1 and S2 are present

Respiratory system

* No wheezing
* No Dysnopea 
* Position of trachea - central
* Vesicular breath sounds

Abdomen

*Schapoid abdomen 
*No Tenderness 
*No palpable mass
*No free fluid 
*No Brits
*Liver and spleen not palpable
*Bowel sounds present

CNS

*patient is Conscious
*No neck stiffness and no kernig's sign
*Normal speech
*cranial nerves, motor and sensory systems are normal.

Reflexes

                      LEFT SIDE         RIGHT  SIDE
*Biceps              2+                       2+                
*Triceps             2+                       2+
*supinator         2+                       2+
*knee                 2+                       2+
*Ankle                2+                       2+


Diagnosis

Chronic kidney failure along with hypertension and diabetes mellitus.

Investigations ordered:

*Serum creatine 
*Serum urea
*CBP
*Serology
*serum Iron
*USG abdomen
*Electrolytes.
*RFT












TREATMENT

Inj. LASIX 40mg/IV/BD
T. NODOSIS550mg/PO/BD
T.SHELCAL 500mg/PO/OD
T.OROFER-XT/PO/OD
T.AMLONG 5mg/PO/OD
Inj. Erythropoietin 4000 IU/S/C
Weekly DNCE
Inj. HAI S/C PRE MEAL
Acc. To SLIDING SCALE /TLD

ABOUT THE CASE:
☆The patient came to OPD with complaints of bipedal edema and decreased urine output.
    ☆By performaning Renal Function tests (RFT) , we can clearly see elevated levels of urea,creatinine in blood.
☆so we can say it is CHRONIC KIDNEY DISEASE ie..renal failure which lead to accumulation of waste products(urea and creatinine ) and water (pedal edema)

My quires: 
● Is kidney transplant is required?

▪Thank you keerthi reddy mam for giving me this information and helping me in this project.

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