Case presentation 2

 21.09.21

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Date of admission:17/09/21

 A 80yr old Male patient came to ward with chief complaints of fever since 15 days loss of appetite since 13 days.

History of present illness:

Pt was apparently asymptomatic 15 days back after which he developed fever and avoided taking food completely due to loss of appetite and frequent urination.

Past history:

Pt had no similar complaints in the past.pt is known case of hypertension.

He is not a known case of asthma, epilepsy,thyroid, tuberculosis,CAD and CVD.

History of hospital visit for fever.

Personal history:

Patient takes mixed diet with poor appetite.normal bowel and increase bladder movements.

Chronic alcoholic and smoker since 40 years.smokes a bundle of cigars per day and consumes a peg every day.

Treatment history:

No history of allergy to any known drug.

On examination:

Patient is conscious,coherent, cooperative.well oriented to time ,place, person

Thin built and and looks malnourished

Temperature: afebrile

BP:140/90 mm of hg

pulse rate:90 beats per min

Respiratory rate:20 per min

CVS:

no thrills,no cardiac murmurs,

 S1 and S2 are heard

Respiratory system:

No dyspnoea and wheezing

Centrally positioned trachea,vesicular breath sounds

Abdomen:

schaphoid shape of abdomen ,no tenderness,no palpable mass,no bruits,no free fluid,liver and spleen are not palpable,bowel sounds are heard,normal genitals.

CNS:

Pt is conscious ,speech is normal,no neck stiffness,normal sensory and motor systems and cranial nerves.

Glasgow scale 15/15 

Provisional diagnosis:

Chronic renal failure

Investigations:

Complete blood picture

Complete urine examination:

Blood urea : # 214 mg/ dl

Serum creatinine : # 14 mg/dl

Serum electrolytes :

Sodium : 140 mEq/L

Potassium : # 5.7 mEq/L

Chloride : # 96 mEq/L

Treatment:

Fluid restriction :<1.5 L/day

Salt restriction:<2gm/day

T.CLINIDIPINE 10mg BD

T.NODOSIS 500 mg BD

T.BIO D3 OD

BP,PR,SPO2,Temp monitoring

T.PLM 650mg   BD