Thakur shalini General medicine case presentation 2

78. Shalini Thakur , General medicine case presentation.


 This is an online e-log  book  to discuss our patient's de- identified health data shared after taking his / her / gaurdians informed consent.here we discuss our individual patient problem through series of inputs from available global online communityof experts with an aim to solve those problems with collective  current best evidence inputs 

This is a case of 32 year old male patient came to casuality with cheif complaint of 1 episode of GTCS , associated with loss of consciousness, involuntary micturation, associated with post ictal confusion for 20 minutes , no history of headache , vomiting and fever 

History of present illness:

Patients complains history of burning micturation , bilateral ureteric calculi , right renal calculi 

Past surgical history of  right PCNL URSL C DJ stenting in November 2020 , 2 sessions of haemodialysis done at that time in view of post renal AKI and discharged on medical treatment

History of past illness:

No h/o decreased urinary output

No h/o shortness of breath

No other complaints

K/c/o T2DM  since 1.5 years

Personal history:

Diet : Mixed

Sleep: adequate

Appetite : Normal

Bowel and bladder movement : normal and regular

Past Treatment History:

Past surgical history of right PCNL URSL C DJ stenting

Family history:

No any similar complications in the family 

General Examination:

Pallor 

No cyanosis

No clubbing

No icterus

No lymphadenopathy

VITALS :


Temperature : 98°F

Pulse rate : 98 beats per min

Respiration : 26 cycles per minute

Spo2 : 99%

GRBS : 191 mg %

Systemic examination :

CNS :

S1 and S2  are heard 

No murmers 

No thrills 

Respiration system:

No dysopnea

No wheezing

Position of trachea : central

Breath sounds : vesicular

Abdomen :

Shape of the abdomen - scaphoid 

No tenderness

Hernia orifice normal

CNS:

Conscious

Speech is normal

Cranial nerves , motor system , sensory system normal

Gassgow scale : 15/15

Provisional Diagnosis:

Chronic Renal Failure

Investigations: Random blood glucose levels

Serum protein
Alkaline phosphatase
Serum albumin
ABG
Serum creatinine
Complete urine examination
Total protiens ratio
Hemogram
Anti HCV antibodies rapid
Hbs Ag Rapid
Serum electrolyte s
Serum Bilirubin total
SGOT

Treatment plan :

1. Fluid restrictions 1.5 lit per day
2. Salt restriction 2 gm per day
3. Injection cephtrioxone 1 gm  IV bd
4.  Tab CASIX 40 mg bd
5. Tab NODOSIS 500 mg td
6. Tab SHELCAL 500 mg of
7. Tab  orofer bd
 GRBS monitering 6 th hourly
Injection LEVIPIl 500 mg IV
Injection HAI SC according to GRBS 
Bp / PR / Temp / Spo2 monitering
 

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