CASE HISTORY - 1
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Date of Admission: 07-08-2021
A 45yr old male patient came to causality with Fever and shortness of breath since 7 days. There is a history of burning sensation during urination.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 1yr back then he noticed fever and shortness of breath and there was low urine output.
The patient is suffering from fever since 10 days which is of continuous type and there is shortness of breath while walking for a short distance
There is a loss of appetite.
PAST HISTORY:
The patient was diagnosed 1yr back with chronic renal failure. He underwent 5 sessions of haemodialysis after which the symptoms were subsided.
No H/o Diabetes, Hypertension, Tuberculosis, Epilepsy
PERSONAL HISTORY:
Appetite: There is loss of appetite
Diet: Mixed diet
Bowel and bladder habits: Normal
The patient is alcoholic since 18yrs
Socioeconomic status: Poor
FAMILY HISTORY: No similar familial history
TREATMENT HISTORY:
INJ. LASIX 40mg I.V BD
TAB. NODOSIS 500mg BD
TAB. B10-D3 PO/BD
INJ. ERYTHROPOIETIN S/C Twice
TAB. OROFER -XT PO/BD
GENERAL EXAMINATION :
The patient was coherent, conscious and cooperative
Built: Ectomorphic
Nourishment: Malnourished
Pallor: Present
Clubbing: Absent
Pedal oedema: Pitting type
No Generalized lymphadenopathy
VITALS:
Temperature: 100.8 degree farenhiet
Respiratory rate: 30/min
Pulse rate: 100/min
Blood pressure: 140/90 mmHg
GRBS: 120 mg%
SYSTEMIC EXAMINATION:
Respiratory system: BAE +VE
CVS: S1 & S2 heard
CNS: NAD
INVESTIGATIONS:
COMPLETE BLOOD PICTURE:
PROVISIONAL DIAGNOSIS:
Chronic Renal failure
INDICATION FOR DIALYSIS:
- Increase in creatinine and urea level above the normal range
- Metabolic Acidosis
TREATMENT:
INJ. MONOCEF 1gm/I.V/BD
Fluid restriction <1.5L/day
Salt restriction <4gm /day
INJ. PAN 40mg I.V/OD
Inj. LASIX 40mg I.V/BD
Strict I/O Monitoring
Tab. NODOSIS 1GM
Tab. OROFER XT PO/BD
Tab. SHELCAL CT PO/OD
INJ. ERYTHROPOIETIN 4000 I.U S/C Weekly once
BP, PR, Monitoring 4th hourly
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