1601006096 LONG CASE

LONG CASE

1601006096

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


This is the case i have been given :

A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine out since 4 months

2. Bilateral pedal edema since 4 months and 

3. Abdominal distension since 4 months

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type, gradually progressed to involve abdomen with abdominal distension, no aggregating and relieving factors. 

There is history of pruritus (evidenced by scratch marks) and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CVA, TB, asthma,CVD & epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

Patient also gives a h/o bilateral Tympanic membrane perforation 6 yrs back (following an infection).

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetwite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions :  h/o beedi smoking 4-5 years ,stopped 1 year back


GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present

• No Icterus, cyanosis, clubbing , koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type grade 2





VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal


SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS :

1. Higher mental functions : Normal

2. Cranial nerves
- Olfactory (1st CN) : Smell present on both sides
- Optic (2nd CN) : visual acuity - 6/6
  Visual field,colour vision,reflexes : normal 
- Occulomotor (3,4,6th N) : ocular movements -present
 Nystagmus, Diplopia-absent
Pupils are reactive and normal
- Trigeminal (5th CN) : motor and sensory functions normal on both sides
 - Facial nerve (7th CN) : Normal
- Vestibulocochlear nerve (8th CN) - Rinnes Weber,schwabach test NEGATIVE on both sides (BILATERAL SENSORYNEURAL HEARING LOSS)
- Glossopharyngeal (9th) : Normal
- Vagus (10th) & 11th CN : Normal
- Hypoglossal (12th) : No deviation of tongue

3. Motor system
- Attitude and position-Normal
- Bulk : no wasting
- TONE: 
           Rt       Lt

UL      N          N

LL      N          N

- POWER :

         Rt        Lt

UL    5/5     5/5

LL     5/5     4/5

- REFLEXES :

• Superficial       Rt      Lt

  Corneal  :      +2      +2

 Conjunctival :  +2    +2

Abdominal :     +2     +2        

• Deep              Rt        Lt

Biceps  :          +2      +3

Triceps :          +2      +2

Supinator :     +2      +2

Knee jerk :      +2      +2

Ankle jerk :      +2      +2

Plantar :  Both are flexors

5. Sensory system  : Normal

6. Cerebellum : Normal
   Co-ordination & gait  : normal

7. No meningeal signs


• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard


INVESTIGATIONS :

Complete blood picture

Complete urine examination


Serum iron

Renal function tests

Liver function tests


Blood grouping & Rh typing


HIV


HbsAg


Anti HCV Antibodies


SARS COVID


USG




ECG 


PROVISONAL DIAGNOSIS:

CKD stage II, secondary to NSAID abuse


TREATMENT GIVEN :

The patient was on hemodialysis along with drugs
Hemodialysis chart



Fluid & salt retention (< 1 litre/day and <2gm/day )
Tab. Nicardia 10 mg TID
Tab. Lasix 40 md BD
Tab. Nododis 500 mg BD
Tab. Shelcol OD
CAP - alpha -D3 OD
Sodium bicarbonate
Injection iron sucrose 100 mg BD
Injection Monocef 1g BD
Injection erythropoietin 4000 iu/ one weekly



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