Final practical examination-long case

FINAL PRACTICAL EXAMINATION- LONG CASE

 Feb 8,2022 

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Chief complaints:

A 60 year old male patient driver by occupation came to  causality with the chief complaints of; 

Pedal oedema since 15 days.  

Vomitings since 1 week

SOB since 5 days.                                              

Fever,cough since 5 days.

Decreased urine output since 3 days

He is a known case of chronic renal failure and he is on hemodialysis and he underwent (4) sessions of hemodialysis.

HISTORY OF PRESENT ILLNESS;

Patient was apparently asymptomatic 15 days back and he is completely normal and he can able to do his regular routine work.  --But 15 days back he developed oedema in his lower limb which is extended up to ankle which is pitting type

-fever which is continuous associated with cough and vomiting  since 5days.vomiting of one episode which is non projectile. Cough with sputum which  is red in colour and reduced after medication.

-SOB of grade 4 since 5 days

-Patient had underwent 7 sessions of hemodialysis till date.

PAST HISTORY;

-He had a H/o giddiness 15 years back for which he went to hospital and diagnosed with diabetes and he discontinued medication since 6 years.

-He had H/o TB 15 years back which is treated with HRZE regime.

-Diagnosed with hypertension since 2 years.

PERSONAL HISTORY;

Diet -mixed

Sleep - not adequate 

Appetite- decreased 

Bowel and bladder movements- normal

Micturition - normal

Patient had a habit of drinking alcohol and chewing pan since 30 years but he had stopped since 3 years.

FAMILY HISTORY;

No relavent family history.

GENERAL EXAMINATION;

-Patient was conscious, coherent, cooperative

-pallor

-No cyanosis, clubbing, lymphadenopathy.

-pedal oedema which is pitting type.

vitals;

Temperature -99.6 F

B.P-140/80mm Hg

PR-85bpm

RR-26cpm

GRBS -237mg

Systemic examination;

CVS S1S2+

RS -BAE +

Per abdomen - soft, nontender

CNS -NAD

Provisional Diagnosis:

Chronic kidney disease on maintenance hemodialysis 

Investigations;

ECG;

Haemogram:

Hb- 7.1gm/dl

TLC- 12,500

Lymphocytes -13

PCV -21.6

MCH- 22.7

RBC count- 3.13 million /cumm

RFT;

Urea-132 mg /dl (nrml 5-10mg/dl)

Creatinine -10.1 mg/dl (nrml:0.7-1.3 mg/dl)

Phosphorus -6.6 mg /dl (nrml 3.4-4.5 mg/dl)

LFT;

Total bilirubin -0.76

ALP - 141

Total protein -5.8 gm/dl

Albumin -2.7 gm/dl

Complete urine culture

Final diagnosis;

Diabetic NEPHROPATHY.

Treatment;

Salt restriction-<2.4 gm/day

Fluid restriction <1 lit/day

Tab lasix 40 mg

Tab SHELCAL 500 mg.

INJ.PAN 40MG 

INJ.ZOFER 4mg

Tab NICARDIA 5mg

Tab Nodosis 500mg 

Tab orofer .