ACUTE ON CHRONIC RENAL FAILURE with pleural effusion and past history of PULMONARY TUBERCULOSIS .

1601006084


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 inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment


HALL TICKET :1601006084


A 45 year old male resident of Nalgonda labourer by occupation presented  with chief complaint of : 
• shortness of breath since 10 days  
• Cough since 10 days 
• Pedal edema since 10 days 


History of presenting Illness:-

Patient was apparently asymptomatic 10 days ago,then developed —
• Grade III  shortness of breath which was insidious in onset , nonprogressive,aggravated by walking  and strenous work  and dressing , relieved by sitting             
               There is history of orthopnea                        
               There is no history of PND 
• Dry Cough  since 10days which is insidious in onset , non progressive ,no aggrevating and relieving factors 
•  Grade III bilateral Pedal edema  since 10 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 
        .      Fever since 10 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 
• History of burning micturition and oliguria since 5 days 
• There is no history of sweating , palpitations , chestpain , hematuria 

Past history 
•    2 years back he developed symptoms of  productive cough and fever for 1 week for which he visited to hospital and diagnosed with TUBERCULOSIS and took  antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable ) 
• Not a known case of diabetes ,hypertension,asthma , convulsions
• Surgical history is not significant.      

Family history 
          Not significant 

Personal history 

•  decreased appetite 
• Mixed diet
• Regular bowel habits and normal 
• Patient has oliguria and burning micturition 
• He is an alcoholic since 10 years  , drinks once   weekly 
• Smoker since 25 years , he smokes daily 2-5 beedis 

 GENERAL EXAMINATION 

   Patient is conscious coherent and cooperative  , moderately built , moderately nourished 
⁃ Presence of pallor 
⁃ No icterus , no cyanosis, no clubbing ,no pedal edema 
⁃ No generalized lymphadenopathy     




  

   

 
 





 Vitals 
⁃ Pulse taken  in sitting position ,left radial pulse ,Pulse rate : 80bpm , regularly regular 
⁃ Bp 130/80 mm hg measured in sitting position on right upper arm 
⁃ Respiratory rate : 20cpm
⁃ Afebrile 
 
RESPIRATORY SYSTEM EXAMINATION 
 
 Patient is examined in supine aswell as in sitting positions under well ventilated room with consent taken 

 Upper respiratory tract :
     nose , oral cavity  are examined and no abnormal findings are present 

 examination of chest proper :
  • Inspection 
⁃ shape of chest : normal 
⁃ Symmetry of chest : symmetrical 
⁃ Trial sign negative 
⁃ Movements of chest : RR -20cpm                  .  
                         Type - abdomino thoracic.                        
  .                      Equal on both sides 
⁃ No involvement of accessory muscles and no intercoastal tenderness 
⁃ No visible scars , no sinuses , no engorged veins 
⁃ No deformities of spine 
⁃  No visible apical impulse 



  • palpation 
⁃ No tenderness and no local rise of temperature 
⁃ Inspectory findings are confirmed
⁃ Trachea central 
⁃ Apex beat : felt at 5 th Intercoastal space  medial to mid clavicular line
⁃ Decreased  chest expansion 
⁃ Vocal fremitus : decreased  at infra axillary and infra scapular areas on both sides                                       normal on supra clavicular , infraclavicular ,mammary , infra mammary , suprascapular and interscapular areas 
.

  •   Percussion 
  1. Direct percussion: resonant on clavicle , sternum 
    2.   Indirect percussion : 
  Anterior :
⁃   resonant in supra clavicular area 
⁃ Resonant in infraclavicular  area 
⁃ Resonant  in inframammary area on both sides 
⁃ Traube’s space:dull  
  Posterior :
⁃ Resonant in suprascapular area 
⁃ Resonant in interscapular area 
⁃ Dull in Infrascapular area on both sides 

  • Auscultation   
⁃ Bilateral air entry present 
⁃ Normal vesicular breath sounds heard 
Reduced in  B/ L infrascapular  and infra axillary areas 
        -       fine crepts heard on B/L infra axillary and infra scapular areas 
 
CVS EXAMINATION 
 
⁃   S1 s2 heard 
⁃ No murmurs 
⁃ No palpable  thrills 

ABDOMINAL EXAMINATION 

 Scaphoid shape 
No tenderness 
No palpable mass 
No hepatosplenomagaly 
No ascites 
Bowel sounds  present 

CNS EXAMINATION 

⁃  Conscious and alert 
⁃ Normal gait 
⁃ Normal speech 
⁃ No signs of meningeal irritation 
⁃ Cranial nerves , motor system , sensory 
⁃ Reflexes : superficial and deep tendon reflexes are intact 

INVESTIGATIONS 

⁃ CBP
⁃ CUE
⁃ Abg 
⁃ RFT 
⁃ LFT
⁃ PT
⁃ APTT
⁃ Blood sugar 
⁃ ESR 
⁃ Serum pottasium 
⁃ Blood culture 
⁃ Chest x ray 
⁃ Ecg 
⁃ Ultrasound abdomen 


    




 

Provisional diagnosis :ACUTE ON CHRONIC  RENAL FAILURE with pleural effusion and  past history of  PULMONARY TUBERCULOSIS .

TREATMENT 

⁃ Salt and fluid restriction 
        Salt - < 2 g/ day 
        Fluid - < 1 lt / day 
⁃ Injection  iv LASIX 40mg BD 
⁃ Tab NODOSIS  500mg bd 
⁃ Tab SHELCAL 500mg od
⁃ Input and output charting 
⁃ Bp  pulse  spo2 charting 

 







Comments

Post a Comment

Popular posts from this blog

ALTERED SENSORIUM SECONDARY TO ? HYPONATREMIA(RESOLVED)WITH ALCOHOL WITHDRAWAL SEIZURE(RESOLVED)WITH PYREXIA SECONDARY TO UTI

Image
*ICU Admission under unit-6*  Under the guidance of DR.VAISHNAVI MAM AND DR.MANASA MAM  45 yr old Male came to casuality with chief complaints of Fever since 2 days in Drowsy state.. Fever - High grade, intermittent, associated with chills HOPI+ pt was apparently asymptomatic 6 days ago, later he developed vomitings-1 to 5 episodes/day, non bilious, non projectile, non blood tinged for which he went to a govt hospital & got treated...  Prior to vomitings pt had intake of alcohol (360ml) 2 days after he had involuntary movements of both upper & tower Limbs (? Generalized tonic clonic seizures) - 1episode, which is associated with froathing, tongue bite.. pt was unconscious during this episode. He was taken to a private hospital & managed conservatively 2 days back patient was conscious & coherent, talking  but he is in drowsy state. Patient stopped working since 1 year (due to generalized weakness ) 2 months back - pt had back pain ( occasionally taken pain killers)
Read more

General Medicine case

                                       CASE DISCUSSION                                                        BY                                        K.ROSHINI REDDY                                ROLL NO - 74 (8TH SEMESTER) Coming to the topic, I have been given this case to solve in an attemot to understand the topic of "patient clinical data analysis"to develop my competency in reading and comprehending clinical data icluding history,clinical findings,investigations and come up with a diagnosis and treatment plan. You can find the entire real patient clinical problem in this link below..... ( https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 ) A 42 year old female patient,came  with severe edema along with G6PD& AMPD1 deficiency and multiple health events. Chief Complaints 1)  Swelling of face and abdomen 2) Migraine with Aura 3) Sleeplessness 4) Weakness on the left side 5) Oliguria 6) Fatigue Reasons for the Above Problems
Read more

?Acute bronchitis, Haemetemesis+, Hemoptysis+

Image
90 yrs old male came to casuality with chief complaints of haemoptysis since 2 days(2 episodes) Pt was apparently asymptotic 2 days ago, later he had cough ass with blood tinged sputum-small quantity H/O similar complaints for the first time 40-50 yrs back  From then on and off for every 6-8 months -Not on medication PAST ILLNESS-  60 yrs back he had a h/o trauma(Accident) to liver, got admitted in hospital and got operated 40 yrs back-He had a h/o trauma(accident) to  right side of his shoulder and got treated conservatively 20yrs back -He had a h/o  trauma to his front side of right leg-femur fracture and got operated 14yrs back he had h/o of trauma to his left eye for which he went through eye surgery(enucleation) in Hyderabad hospital and his eye got removed. No H/o asthma,TB, epilepsy, CAD, DM, HTN On examination :  Pt is c/c/c No signs of pallor, icterus, cyanosis, clubbing, lymphadenoapathy, edema Vitals: Afebrile PR: 80 bpm, regular RR: 20 cpm BP: 130/80 mmHg SPO2:
Read more