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:

              

ULTRASOUND:

BLEEDING & CLOTTING TIME:

COMPLETE URINE EXAMINATION:

RENAL FUNCTION TEST:

ARTERIAL BLOOD GAS:

ECG:

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