1601006200 LONG CASE

 

LONG CASE FOR PRACTICAL EXAMINATION


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A 50yr old Male from Dhaamera came to the OPD with the chief complaints of swelling in face and both the legs since 3 months .


HOPI :


The patient was apparently asymptomatic 1 year ago when he developed

Oliguria - insidious in onset and gradual in progression since 1 year.

Facial puffiness- insidious in onset and gradually progressive since 3 months

Pedal edema - bilateral, insidious in onset and gradually progressive since 3 months that started from the feet and progressed to the level of below the knees(grade 2). Aggravated on fluid intake and not relieved on rest.

No associated dribbling of urine, thin stream, forced micturition, suprapubic pain, dysuria.

No history of fever, burning micturition, hematuria, pruritus, easy bruisibilty,
palpitations, dyspnoea on exertion.

Past history:

No history of similar complaints in the past.
Patient is a known case of hypertension since 3 years for which he took medication irregularly.
Not a known case of Diabetes mellitus, TB, Epilepsy, Asthma, Thyroid disorders.

No significant surgical history.

Family history : not significant

Personal history :
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Bladder and bowel - Decreased urine output
                                    Irregular bowel movements
Addictions - Beedies 3/day since 10 years.

Drug history : No known drug allergies



General examination:

The patient is conscious, coherent, cooperative.
Poorly built and poorly nourished. (BMI 15.2)

Pallor- Present
Icterus- Present
Cyanosis - Absent
Clubbing - Absent
Koilonychia - Absent
Lymphadenpathy - Absent
Pedal edema - Present(grade 2)





Vitals

Temperature - afebrile
Pulse - 82 /min
Blood pressure -150/80 mm hg
Respiratory rate - 16cpm
SpO2 - 98%

BP Chart 



Systemic examination:

Per abdomen
Inspection - 
Shape is scaphoid 
Umbilicus is central and everted
All quadrants moving equally with respiration
No visible scars, sinuses,pulsations
Palpation - No tenderness, No organomegaly
THE KIDNEYS ARE NOT BIMANUALLY PALPABLE.
Percussion - tympanic note
Auscultation - Bowel sounds heard




Respiratory system
Inspection - Trachea central, Symmetrical chest expansion
Palpation- Bilaterally Symmetrical chest expansion
Percussion - Resonant note
Auscutation- NVBS present
Bilateral air entry present
No added sounds

Cardiovascular system
Inspection -
Symmetrical chest
No visible pulsations
Palpation - S1 S2 heard, No murmurs

Central Nervous system
HMF intact
Cranial nerves intact
Sensory and motor system intact
Cerebellar function  intact

Investigations:


1. Complete blood picture

- Hemoglobin 6.8 g/dl


2. Complete urine examination

- Albumin +2


3. Renal function test

- Raised urea 131 mg/dl
- Raised creatinine 7.1 mg/dl


4. Liver function tests


5. Ultrasound 

Impression

- Few cysts noted in the left kidney
- B/L kidneys grade 3 RPD



6. ECG


Interpretation of ECG:


- Rate- 100 beats/ min

- Normal sinus rhythm 

- Normal axis

- p wave, qrs complex, t wave, pr interval, st  segment - all appear to be normal 


Provisional diagnosis: Chronic kidney disease due to uncontrolled hypertension.

Treatment history:
Tab. Furosemide 40mg OD
Tab. Nifedipine SR 10mg BD
Tab. Clonidine 100mcg OD
Tab. Sodium bicarbonate 500mg OD
Tab. Pantoprazole 40mg OD
Calcitriol capsules OD
Ferrous ascorbate and folic acid tablets OD



He is on dialysis since 1 month. He has undergone 13 sessions of dialysis till date.




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