Final practical exam long case
Final practical exam-long case
February 09.22
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A 60 year old male patient driver by occupation came to causality with the chief complaints of;
Pedal oedema since 15 days.
SOB since 5 days.
Fever 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;
He was 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
- After completion of (6) session of dialysis he has gone through acute ischaemic stroke.
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 - adequate
Appetite- Normal
Alcoholic since 30 years.
FAMILY HISTORY;
No relavent family history.
GENERAL EXAMINATION;
-Patient was conscious, coherent, not well 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
Investigations;
ECG;
Hb- 7.1gn/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;
MRI Brain;
It confirms that there is a few infarcts in right corona radiata.Age of infarcts is 12-16 hrs.
Provisional diagnosis;
CKD on MHD
Final diagnosis;
Diabetic NEPHROPATHY.
Treatment;
Salt restriction-<2.4 gm/day
Fluid restriction <1 lit/day
Tab lasix 40 mg
Tab SHELCAL 500 mg.
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