60-year-old male daily wage laborer

INTRODUCTION-

This is online E logbook 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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