GENERAL MEDICINE CASE DISCUSSION

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 box.


This is a case of a 60 year old male presented with the chief complaints of decreased urine output since 2 months.

Patient was apparently asymptomatic 2 months back, then he developed burning micturition followed by decreased urine output. 
The patient complained of neck pain since 1 month.
No h/o pedal edema, facial puffiness, shortness of breath.
No h/o similar complaints in the past.
Not a k/c/o DM, HTN, asthma, TB.


VITALS :
Temperature - Afebrile
BP - 110/70 mm Hg
PR - 92 BPM
RR - 22/min
SpO2 - 98% at RA


On examination :
CVS : S1 S2 present, no murmurs
RS : NVBS heard
CNS -  NAD
P/A - Abdominal distension present, non tender.


Investigations : 


Provisional Diagnosis :
Chronic kidney disease


Treatment :
1. Tab NICARDIA 20mg PO / OD
2. Tab NODOSIS 500 mg PO/ BD
3. Tab SHELCAL PO /OD
4. Tab OROFER XT PO / BD
5. Tab ULTRACET 1/2 tab PO / QID
6. Tab PAN 40 mg PO/ OD
7. Inj ERYTHROPOIETIN 4000 IU SC weekly once
8. Fluid restriction < 1litre / day



On 4/1/2022 :

CKD ward case , 60Y/M

S : No fever spikes, no fresh complains


O : 
Pt is c/c/c
BP - 130/80 mm Hg
PR - 88 bpm
Temperature - 97 F
CVS - S1 S2 present, no murmurs
RS - BAE present
CNS - NAD
P/A - Abdominal distension present, non tender


A : 
CKD on MHD


P :
1. Tab NICARDIA 20mg PO / OD
2. Tab NODOSIS 500mg PO/BD
3. Tab SHELCAL CT PO/ OD
4. Tab OROFER XT PO/BD
5. Inj ERYTHROPOIETIN 4000 IU weekly once
6. Fluid restriction < 2l/day
7. Tab ULTRACET 1/2 tablet QID
8. Inj PAN 40mg OD
9. Tab NEUROKIND R OD
10. Neb with BUDECORT 5th hourly
11. Neb with DUOLIN 5th hourly
12. Vitals monitoring

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