INTRODUCTION
This is online E log book to discuss our patient’s de-identified health data shared after taking his 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 patients clinical problems with collective current best evidence based inputs
60-year-old
male daily wage laborer came to OPD with complaints of-
Chief complaint- patient came to hospital 1 week back with complaints of
anuria and constipation.
History of present illness- patient was apparently asymptomatic 1 year back, he
developed anuria and went to Sri Chakra hospital where he received 6 dialysis over
13 days. He as normal till 1 week back when he developed anuria again and came
to our hospital. He has received 4 dialysis sessions in 1 week.
History of past illness- no history, 1st time admission in hospital
Family history- no significant family history
Personal history- smoking 1 cigarette/day and 90 ml alcohol/day. Mixed diet.
General examination- truncal obesity present. No pallor, icterus, cyanosis, koilonychia,
lymphadenopathy, edema.
CVS-
no thrills. S1, S2 heard. No murmurs.
RS-
no dyspnea. No wheeze, central trachea. Vesicular breath sounds. No adventitious
sounds.
Abdomen- truncal obesity-
CNS-
patient is conscious, coherent and cooperative, speech is normal. Motor and
sensory system normal.
Investigations-
· GRBS-
· Creatinine-
· ECG-
· LFT-
·
2D echo-
· Electrolytes-
· Iron-
· Urea-
Provisional diagnosis- chronic renal failure
Treatment-
10/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
11/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
12/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
13/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
14/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
15/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
15/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
16/11/21-
·
Fluid restriction
·
Salt restriction
·
LASIX
·
NODOSIS
·
SHELCAL
·
PAN D
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