Final practical examination-long case

 This is an online E log book to discuss our patient's          de-identified health data shared after taking his / her guardians signed informed consent. Here we discuss our individual patient's problems through a 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 .This E log book reflects my patient centered online leading portfolio and your inputs on the comment box is welcomed."

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

Pedal oedema since 15 days.  

SOB since 1week.        

Vomting since 1week.                                      

Fever since 1week.

Decreased urine output since 1week .    

He is a known case of chronic renal failure and he is on hemodialysis and he underwent 7 sessions of hemodialysis.


HISTORY OF PRESENT ILLNESS;

He 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 1week.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 1week.


PAST HISTORY;

-He had a H/o dizziness  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.

-he had H/o hypertension since 2 years.


PERSONAL HISTORY;

Diet -mixed

Sleep - adequate

Appetite- Decrease 

Bowel and bladder movements- normal

Alcoholic since 30 years.

FAMILY HISTORY;

No relavent family history.

General examination:

Patient was conscious, coherent, not well cooperative

-pallor present 

No cyanosis, 

No H/o clubbing, 

No H/o 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+


Respiratory system: bilateral air entry present, wheezing present, position of trachea central.


CNS: patient is conscious and coherent.


Per abdomen - soft, nontender

Investigations;

ECG;




Hb- 7.1g/dl

TLC- 12,500

Lymphocytes -13

PCV -21.6

MCH- 22.7

RBC count- 3.13 million /cumm

RFT;

Urea-132 mg /dl

Creatinine -10.1 mg/dl

Phosphorus -6.6 mg /dl


LFT;

Total bilirubin -0.76

ALP - 141

 Total protein -5.8 gm/dl

Albumin -2.7 gm/dl

Complete urine culture;


Provisional diagnosis;

Chronic kidney disease on maintenance hemodialysis 


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 








                                                                                             

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