This is an online E - log book to discuss our patients 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 portfolio and your valuable inputs on the comment box.
A 42 year old male , resident of Choutupal Who is daily wage labourer by occupation came to opd for regular dialysis.
History of presenting illness:
Patient was apparantly asymptomatic 1 .5yr back
Then after taking covid vaccination he developed fever
Fever was present through out the day
Not associated with vomitings,nausea,burning micturition .
Generalised weakness was present
Didnt relieve on taking medication also
So he visited our hospital.
Then he was diagnosed with hypertension and renal cyst. For which he was given medication.
After 6 months he developed shortness of breath and pedal edema upto ankle for a week. Then they visited Gandhi hospital
Where dialysis was done for him and was admitted in hospital for nearly 20 days
And then medication was given.
2 months back he developed shortness of breath and generalised weakness again
Now he visited our hospital. His hemoglobin levels are low so blood transfusion of 4 units was done .since then he was on regular dialysis which is twice in a week.
15 days back after dialysis was done
He developed watering eye in the right eye,peri orbital swelling was developed,tenderness was present,no eryyhema
And then gradually vision was lost in that eye with in 5 days.
After 7 days he noticed nasal bleeding from right nostril. He also develped an ulcer like
Wound on his right dorsum of nose.He also developed a swelling on the head on right side for which he was treated with fudic ointment.
Past history
Known case of hypertension since 1 year and on medication
Initially 1 year back he used to take 1 tablet /day now he is using 3 tablets / day
Not a known case of diabetes,TB,asthma
Personal history
Mixed diet
Appetite is reduced
Normal bowel and bladder movements
Sleep is adequate
Addictions
Chronic alcoholic
Daily consumption of alcohol around 250 mL for around 20-25 yrs and stopped 1 1/2 yr back
Daily routine
Before
He used to wake up at 5:00am and does some house hold works and goes to work at 8:00 am after having breakfast and returns home at 3:00 pm for lunch and goes back to work and again returns home back between 8-9pm and will have dinner and sleep
Now
He wakes up around 7:00 am and after taking shower will have breakfast by 8:00 am and then sleeps again and wakes up at 2:00 pm for lunch takes his medications and sleeps again and wakes up again at 8 pm will have dinner and sleeps again.
Family history:
Not significant
General examination
Patient was conscious ,coherent and well oriented to time and place.
Patient was moderately built and nourished
Vitals
BP 140 /90 mm of Hg
Pulse 80beats /min
Temperature afebrile
Respiratory rate 16 cycles/min
Pallor is present
No icterus,cyanosis,clubbing,lymphadenopathy
Local examination
Eye:
Right eye
Mild swelling of upper lid is present
Loss of vision is present
There Is no counting fingers ,perception of light
Ocular movements are limited in all
Directions
Light reflex is absent
On palpation mild tenderness is seen
Nose
Epistaxis from right nostril
Mild tenderness is present in maxillary region.
Ulcer like wound is present om the right dorsum of nose.
Head:
Single follicular cyst was seen on right side in frontal region
Which was relieving with medication
Systemic examination:
CVS- S1 S2 heard no murmurs
CNS- No focal neurological deficit
RS- Normal vesicular sounds heard
Provisional diagnosis:
Chronic kidney disease
Investigations:
Comments
Post a Comment