57 YR OLD MALE WITH LOWER BACK PAIN AND CHEST PAIN

 I am Soumya 5th semester student .

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CHEIF COMPLAINTS

Since 5 days : 

      Generalized body weakness 
       Pain over upper abdomen 
       Bilateral pedal edema 
       Burning sensation of both soles
- SOB at rest since 3 days


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 5 days ago he developed generalised body pain which is aggravated on exertion and relieved on medication.
- He also experienced burning pain over epigastric region which is also aggravated on exertion and relieved on medication.
- Fever was also present with chills and rigors.
- Bilateral pedal edema was developed which aggravated on walking and relieved on rest.
- Burning sensation of both soles which is present through out the day and SOB at rest.
- Nausea and giddiness since yesterday.

HISTORY OF PAST ILLNESS

K/c/o Chronic kidney disease
( Use of NSAID'S for 1 year due to pain near 1st metatarsal joint and foot )

Diabetes - No

Hypertension - No

TB - No

Asthma - No

Epilepsy - No

CVD - No

Chemo/Radiation Exposure - No

Surgical history - Nil


FAMILY HISTORY

not significant

PERSONAL HISTORY

Diet -  Mixed

Appetite - lost since 10-15 days

Bowel and bladder - Regular movements 

Allergies - No

Addictions - Chewing tobacco

- 90 ml of whiskey occasionally (Once in a month) but stopped 4 months ago 


GENERAL EXAMINATION













  • O/E
  • Pallor: present 
  • Icterus: absent
  • Cyanosis: absent
  • Clubbing of fingers: absent
  • Lymphadenopathy: absent
  • Oedema of feet: present pitting type
      Vitals:
  • PR : 96 bpm
  • Temp : 102  F 
  • RR : 34 cpm
  • BP : 180/90 mmHg

SYSTEMIC EXAMINATION
 CVS: 
    Thrills: no
    Cardiac sounds:S1 ,S2 present 
    Murmurs : absent 
 RS:
    Dyspnea and Wheeze are present
    Position of trachea: central
    Breath sounds: vesicular 
 Abdomen


    Shape of abdomen: scaphoid 
    Tenderness: No
    Palpable mass: no   
    Bowel sounds :Present 


 CNS :
  •    normal  
  •  Patient is Consious, Coherent, Well oriented to time place and surroundings

PROVISINAL DIAGNOSIS


CHRONIC RENAL FAILURE 


  
 INVESTIGATIONS











27/8

                     










30/8



HIV 1/2 Rapid - Non reactive
HBsAG Rapid - Non Reactive
Anti HCV Antibodies Rapid - Negative
Blood group - B Neg





31/8




1/9










30-08-2022

Diagnosis : CHRONIC RENAL FAILURE 

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


31-08-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever and chest pain

On examination : 

Patient is C/C/C

BP : 120/60 mm of Hg

PR : 82bpm

CVS : S1, S2 present

 RR : 22 cpm

RS : BAE +

P/A soft 

CNS : NAD

Temperature : 101°F

GRBS : 97 mg/dl

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


01-09-2022

Diagnosis : CHRONIC RENAL FAILURE with intermittent fever , left side chest pain and left knee , ankle pain.

On examination : 

Patient is C/C/C

BP : 110/60 mm of Hg

PR : 76bpm

CVS : S1, S2 present

 RR : 24 cpm

RS : BAE +

P/A soft  and non tender

CNS : NAD

Rx :

1. Fluid and salt restrictions 

2. Inj lasix 40mg IV / BD 

3. Tab.Pantop 40mg PO/OD 

4. Tab. Dolo 650mg PO/TID 

5. Inj. Neomol 1g IV / SOS if temperature greater than 101°F 

6. Tab. Nodosis 500mg/PO/TID 

7. Tab. Shelcal 500mg PO/OD 

8. Cap bio D3 PO/weekly once 

9. Tab. Ultracet half PO/BD for 3 days 

10. Syp. Aristozyme 15 ml PO/TID (20 min before food) 


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