Butti Sonali General medicine Case presentation 2

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.

A 28 year old male patient who is a business man by occupation came with the chief complaint of 
Sudden weight loss
Decreased urine output 
Easy fatigue and tiredness
No history of headache, vomiting and fever.

History of present illness:

Patient complains history of decreased appatite and generalized itching later he visited a hospital where he diagnosed with renal failure and hypertension.he had undergone 14 sessions of hemodialysis.
He is currently undergoing hemodialysis.

History of past illness:

He is a known case of hypertension
H/O decreased urine output 
H/O shortness of breath 
No H/O pedal edema
He is not a known case of diabetis , epilepsy, tuberculosis, asthma .

Personal history:

Pt has loss of appetite
Diet:mixed
Bowel and bladder movements: normal
Sleep: adequate
Addictions: Alcoholic occasionally

Family history:

There is no similar complains in family members.

Past treatment history:

He is not a known case of any drug allergy.

General Examination

Patient is conscious, coherent, cooperative at time of joining
Pallor is present
No icterus
No cyanosis
No clubbing
No pedal edema


Vitals:

Temperature--Afebrile
Pulse rate:80 BPM
Respiratory rate--17cycles/min
Bp--160/100
Spo2:99%

Systemic examination:

CVS

Inspection - chest wall is bilaterally symmetrical

No precordial bulge 

No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard


RESPIRATORY SYSTEM

Position of trachea is central 

Bilateral air entry us normal

Normal vesicular breath sounds heard

No added sounds


PER ABDOMEN 

abdomen is not tender

bowel sounds heard 

no palpable mass or free fluid


CNS

Patient is conscious

Speech is present

Reflexes are normal.



Investigations:

Hemogram 
CBP


Serum potassium 




Serum creatinine 



Renal function test 


Liver function test:





Serology:



Diagnosis: Chronic kidney Disease on MHD


Treatment plan:


Tab Lasix 20mg po/BD
Tab Nicardia 20 mg po/BD 
Tab Nodosis 500mg po/TID
Tab orofer XT po/BD 
Tab XD3 0.25mg po/OD
Inj Erythropoietin 4000IU s/c once weekly
Monitor vitals 4th hourly.

Questions: 

--What are symptoms of increased creatinine level?
--How can increased creatinine levels effects body systems?
--What is relationship between creatinine and kidney failure?
--Why not he is case of edema?




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