General medicine case presentation 5
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
A 15 years old male patient studying 9th class came to casuality with complaints of shortness of breath since 4 hours associated with acute chest pain since 4 hours.
History of present illness:
Patient was apparently asymptomatic 1 month back , patient complains of vomitings 2 to 3 episodes daily associated with food particles and not associated with blood.
Patient gives history of fever 1 month back associated with chills which is relieved by using medication for 2 days.
Incidentally he diagnosed raised urea 63 mg / dl and raised creatinine 8.3 mg/dl went to Hyderabad with in one day urea has raised to 135 mg/dl and creatinine 10 mg /dl and started him on dialysis .
5 sessions of hemodialysis done and USG -ABD showing bilateral kidney size of 8.1 cm and loss of CMD increased echotexture grade 3 RPD changes. Since then he was on hemodialysis.
Patient complains of SOB aggrevating on supine position .
Patient complains of chest pain dragging type
Patient no complaints of palpitations , syncopal attack , decreased urine output , pedal edema ,facial puffiness.
Past history :
Patient has no history of Diabetes mellitus, hypertension , tuberculosis, epilepsy ,Asthma.
Family history: no similar complaints in the family
Drug history : patient has undergone 3 cell packs of blood
Personal history:
Diet : mixed
Sleep: adequate
Appetite: normal
Bowel and bladder movements : regular
Habits : no addictions
General examination :
Pallor
No cyanosis
No clubbing
No icterus
No lymphadenopathy
Pedal edema
Vitals :
Temperature : 98.6 F
Pulse rate : 96/min
Respiration rate : 24 cps
Bp 140/100
Spo2 : 86%
GRBS : 121 mg %
Systemic examination:
Cardiovascular system:
S1 and S2 heard
No thrills
No murmers
Respiration system:
Patient suffers with dysopnea
No wheezing
Position of trachea central
Abdomen :
Shape of abdomen :scaphoid
No tenderness
No palpable masss
Hernial orifice normal
Spleen and liver no palpable mass
Central nervous system:
Patient is conscious, coherent.
Speech is normal
provisionalDiagnosis:Acute kidney injury
Investigations:
Comments
Post a Comment