Elog General medicine 

This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent

Ch.Janani

Roll no. 29

Case scenario

A 40 yr male patient resident of Nagarjuna Sagar came to OPD with bilateral pedal edema since 3 months .

Chief complaints

Pedal edema since 3 months with facial puffiness and decreased urine output since 3 months .

Complaints and duration 

Dialysis intiated on 15/10/21

4 session of hemodialysis done 20 PRBC  transfused 

History of present illness

Now came for readmission

History of past illness

No history of past illness

Personal history

Married

Occupation: farmer

Appetite : Normal

Mixed diet 

Bowel and bladder movements are normal 

Family history

Not k/c/o diabetes,HTN,heart disease,stroke,cancer, tuberculosis,asthma

Physical examination

No pallor,no cyanosis,no lymphadenopathy,no icterus,no clubbing

VITALS

Temperature:98.4 F

Pulse rate 84/ min

Respiration rate: 24/ min

BP : 130/70 mm Hg 

SpO2- 98%

Systemic examination

CVS

No thrills ,no cardiac murmers,S1, S2 are heard 

Respiration system

No h/ o dyspnoea, wheezing

Breath sounds : vesicular 

Abdomen 

Scaphoid

No h/o of tenderness,palpable mass 

Non palpable liver and spleen

CNS 

Conscious 

Speech: normal 

Cranial nerves,sensory system,motor system are normal.

PROVISIONAL DIAGNOSIS 

CKD on MHD 

Dialysis started on 15/10/2021

4 session of hemodialysis done 

Investigations 









Serum creatinine : 8 mg/ dl ( 0.9-1.3 )

Sodium : 138 mEq/L 

Potassium : 4.1 mEq/L 

Chloride : 97 mEq/L 

Blood urea : 160 mg / dl (12-42)

Blood sugar -random 

RBS : 93 mg/ dl (100 - 160 )

Blood group: B 

RH typing : positive

Treatment

Fluid restriction <1.5 lit / day 

Salt restriction < 2 gm/ day 

Tab LASIX 40 mg ×PO×BD 

Tab NODOSIS 500 mg× PO×BD 

Tab SHELCAL CT ×PO×OD 

Tab BIO - D3 0.25 mg× PO×OD 

Tab OROFER × 5×PO×OD

INJ ERYTHROPOIETIN 4000 IU/sc ( weekly once)














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