GENERAL MEDICINE CASE

SHIVANI KOMMERA

CASE OF A 37 YEAR OLD MALE WITH C/O FEVER,COUGH SINCE 3 DAYS.

• A 37 year old male patient , married and has 2 children , tractor driver by occupation , resident of chityala came with the

CHIEF COMPLAINTS 

 

• Fever since 3 days 

• Cough since 3 days 

• Loss of appetite since 3 days 

• Blackish discoloration of stools ( Malena ) since 3 days 

• Decreased sleep since 3 days 

• Loose stools since 2 days 

HISTORY OF PRESENT ILLNESS 

 

Patient was asymptoghmatic 5 years ago.

• 4 years ago he had yyh abdominal pain followed by shortness of breath for which he was taken to a hospital in Hyderabad where he was found to have  deranged RFT . 2 sessions of hemodialysis was done and was admitted in hospital for 8 days and got discharged ( indication unknown ) . Since then he was on conservative treatment for 3 years 

• After discharge he quit doing his usual work driving tractor due to his ongoing health issues and restricted to home .

 

• He was tested positive for covid 1 year ago and recovered .

• 6 months back he presented to our casuality with complaints of Facial puffiness, pedal edema pitting type extending up to the knee, decline in urine output and shortness of breath ( which progressed from grade 3-4 ).

Patient BP was high and on ventilator at the time of admission . 5 sessions of hemodialysis was done and was admitted in hospital for 10 days . 

Blood sugar levels were found normal on subsequent testings and patient stopped using Oral hypoglycemic medications .

• He was on regular maintainance hemodialysis twice a week and 4 units of PRBC transfusion done in a 6 months period. 

• He was asymptomatic 3 days before admission . He came for regular dialysis and developed 104°F  high grade fever the very next day associated with Chills and dry cough

He had poor appetite (decreased than usual)

Decreased sleep and blackish discoloration of stools and loose stools since 2 days .

PAST HISTORY 

H/o Type 2 DM 5 years back ( stopped medication 6 months back )

H/o HTN since 6 months (tab Nicardia 10mg)

No H/o Bronchial asthma 

No H/o TB 

No H/o Epilepsy 

No H/o Thyroid disorders

PERSONAL HISTORY 

Diet - Mixed 

Appetite - Decreased 

Sleep - Decreased 

Bowel movements - Regular 

Decreased urine output 

• Chronic alcoholic since 10 years . And he quit 4 years back .

FAMILY HISTORY 

No H/o DM , HTN , CVA , CAD , Bronchial asthma , Thyroid disorders , epilepsy in the family  .

GENERAL EXAMINATION 

Patient is concious , coherent , co-operative 

Moderately built and moderately nourished 

• Pallor + 

• Icterus - 

• Cyanosis - 

• Koilonychia -

• Clubbing - 

• Lymphadenopathy - 

• Oedema - 

VITALS 

Temperature - 104°F

Pulse rate - 96 bpm

Respiratory Rate - 16 cpm

BP - 140/80 mmHg 

SPO2 at room air - 98%

GRBS - 114 mg/dl 

SYSTEMIC EXAMINATION 

Cardiovascular system 

INSPECTION

Chest wall is bilaterally symmetrical .

No precordial bulge .

No visible pulsations, engorged veins, scars, sinuses .

PALPATION

JVP - Normal 

APEX BEAT - Felt in the left 5 th intercostal space in the midclavicular line .

AUSCULTATION

 

S1 S2 heard .

No murmurs 

Respiratory system 

Position of the trachea  - Centre 

Bilateral air entry +

Normal vesicular breath sounds heard 

No added sounds .

 

Per abdomen 

Abdomen is soft , non tender 

Mild Hepatosplenomegaly

Bowel sounds heard 

No palpable mass 

No free fluid .

Central nervous system 

Patient is Conscious 

Speech: normal

No signs of Meningeal irritation

Motor & sensory system: normal

Reflexes: normal

Cranial nerves: intact 

GCS SCORE - 15/15 

PROVISIONAL DIAGNOSIS - 

CKD ON MHD

WITH CLINICAL MALARIA

K/C/O HTN since 6 months

Dialysis started on june 2021 .

•   RTPCR NEGATIVE 

Treatment 

DAY 1

1.Fluid restriction <1.5 lts/day

2.Salt restriction <2gm/day

3.Tab Pantop 40mg PO/BD

4.Tab NICARDIA 10 mg PO/OD

5.Tab NODOSIS 500mg PO/BD

6.Tab SHELCAL CT PO/OD

7.Tab BIO D3 0.25 mg PO/OD

8.Tab LIVOGEN Z PO/OD

9.Inj Erythropoietin 4000IU SC weekle once

DAY 2

1.Fluid restriction <1.5 lts/day

2.Salt restriction <2gm/day

3.Tab Pantop 40mg PO/BD

4.Tab NICARDIA 10 mg PO/OD

5.Tab NODOSIS 500mg PO/BD

6.Tab SHELCAL CT PO/OD

7.Tab BIO D3 0.25 mg PO/OD

8.Tab LIVOGEN Z PO/OD

9.Inj Erythropoietin 4000IU SC weekle once

10 Inj PIPTAZ 4.5 gm IV stat

               ↓

   2.25 gm IV/TID

11.Tab PCM 650 mg PO/TID

12.Inj NEOMOL 1gm IV/sos

13.SYP ASCORIL 15 ml PO/TID

DAY 3

1.Fluid restriction <1.5 lts/day

2.Salt restriction <2gm/day

3.Tab Pantop 40mg PO/BD

4.Tab NICARDIA 10 mg PO/OD

5.Tab NODOSIS 500mg PO/BD

6.Tab SHELCAL CT PO/OD

7.Tab BIO D3 0.25 mg PO/OD

8.Tab LIVOGEN Z PO/OD

9.Inj Erythropoietin 4000IU SC weekle once

10.Tab PCM 650 mg PO/TID

11.Inj NEOMOL 1gm IV/sos

12.Syp ASCORIL D 15ml PO/TID

13.Neb with budecort 12th hourly

14.Inj FALCIGO 120 mg PO/IV

15.Tab DOXYCYCLINE 100 mg PO/BD

DAY 4

1.Fluid restriction <1.5 lts/day

2.Salt restriction <2gm/day

3.Tab Pantop 40mg PO/BD

4.Tab NICARDIA 10 mg PO/OD

5.Tab NODOSIS 500mg PO/BD

6.Tab SHELCAL CT PO/OD

7.Tab BIO D3 0.25 mg PO/OD

8.Tab LIVOGEN Z PO/OD

9.Inj Erythropoietin 4000IU SC weekle once

10.Tab PCM 650 mg PO/TID

11.Inj NEOMOL 1gm IV/sos

12.Inj FALCIGO 120 mg IV

13.Tab DOXYCYCLINE 100 mg PO/BD

DAY 5

1.Fluid restriction <1.5 lts/day

2.Salt restriction <2gm/day

3.Tab Pantop 40mg PO/BD

4.Tab NICARDIA 10 mg PO/OD

5.Tab NODOSIS 500mg PO/BD

6.Tab SHELCAL CT PO/OD

7.Tab BIO D3 0.25 mg PO/OD

8.Tab LIVOGEN Z PO/OD

9.Inj Erythropoietin 4000IU SC weekle once

10.Tab PCM 650 mg PO/TID

11.Inj NEOMOL 1gm IV/sos

12.Inj FALCIGO 120 mg IV

13.Tab DOXYCYCLINE 100 mg PO/BD

                  

This is an ongoing case of CKD and details will be updated . 

This elog is done under the guidance of Dr. Durga krishna sir ( General Medicine ) PGY2 .