GENERAL MEDICINE. Dec 7th 2021

 GUNDAMALA CHAITANYA.
3 rd sem
Roll no 47

 This is online E log book to discuss our patients health data shared after taking his guardians informed consent form

I have been  given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findingsfindings investigations and come with a diagnosis and treatment plan. .

*50 year old male came with chief complaints of fever and Altered sensorium. 
High grade fever associated with chills and rigors, not associated with  loose stools ,headche , cold, cough, seizures and loss of consciousness .
*He was apparently asymptomatic 6 yrs back then he had thrown prick to right leg because of Non healing ulcer  on routine investigation he was diagnosed with Diabetes mellitus and hypertension and on irregular medication. 
*2 yrs back he had complaints of pedal edema  insidious onset gradually progressive upto b / l  upto knee not associated with decreased urine outputoutput, facial puffiness and frothing urine. 
Pt admitted in hyd with c/o pedal edema and sob and diagnosed with Renal failure. . Later 5 dialysis sessions were done.
Since then  pt  was on Medical management.
He had no complaints for 8 months
Then developed  loose stools and vomitings , 15days back visited our hospital and pt was initiated on dialysis  in view of metabolic acidosis.. pt was twice weekly on dialysis.

PERSONAL HISTORY:
Married
Occupation : daily wage worker
Diet:mixed
Appetite: Decreased
Bowel and Bladder : Regular
No addictions
No known allergies

FAMILY HISTORY:
No family history of Dm,Htn, stroke , Tb, Asthma , cancers.

TREATMENT HISTORY:
Took Treatment for Dm,Htn 
5 blood transfusions

GENERAL EXAMINATION:
Altered sensorium
No pallor,Icterus,cyanosis, clubbing, lymphadenopathy
VITALS::
Temp: 98.6
Bp: 120/80mmHg
PR:98 / min
RR :20/ min
SpO2 :98% on RA.

SYSTEMIC EXAMINATION:
CVS:S1,S2 present
Rs: BAE,NVBS
P/A: soft,non tender
CNS ::
Pt is Altered sensorium not oriented with time and place
Speech : SLURRED
Sensory system : Intact
Motor system: 
                          R.                 L
Tone    UL.      Increased.             -
          LL       Hypotonic              -

Power   UL          1/5                3/5
           LL           1/5                3/5
Reflexes    B   T   S   K   A     P
        R   1+.   1+  -     -     -     Flexor
        L.  1+    1 +   1+   -     -     Flexor

Gcs  : E4V1M4
Meningeal sign : Neck stiffness present
 
DIAGNOSIS ::
CHRONIC KIDENEY DISEASE  on Maintaining Hemodialysis with ACUTE PYOGENIC  BACTERIAL MENINGITIS with  k/c/o DM , HYPERTENSION.

25/10/2021.
ECG:
BGT : AB +ve
Serology: Negative
26/10/2021
ECG :
2 D Echo
Chest X ray

27/10/2021 
ECG :
chest X ray
25/11/2021/11/2021
Blood urea :266
Serum creatinine :6.3
Uric acid: 8.1
Na : 139
K : 3.6
Cl : 92
FEVER CHART
TREATMENT given
Hemodialysis on 
25/10/2021.      2/11/2021.      24/11/2021
28/101/2021       6/11/2021.      25/11/2021
Inj.DEXAMETHASONE 8 mg IV
Inj.PAN 40 mg IV
Inj.ERYTHROPOIETIN 400 IU SC once a week
Tab  NODOSIS 500 mg 
Tab  SHELCAL
Tab OROFEROROFER
Inj.FALCIGO 120 mg
Inj.MEROPENAM 
Fluid Restriction <1L / day
Salt Restriction <2 mg / day.
Rt feed  100  ml Mik  4 th hr daily
           100 ml water 4 hr daily.

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