FINAL EXAM BLOG -LONG CASE

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

A 62 Years old male patient came to opd with the chief complaint of :- 
Routine follow up for renal failure On haemodialysis

• History of present illness :- 

Patient was apparently asymptomatic 10 yrs back then he had developed fever , difficulty in having food and was taken to hospital and incidentally found to have Diabetes mellitus And started on conservative management 
3yrs back Pedal edema , facial puffiness And was not treated for it 
2 yrs back Taken to local RMP And was diagnosed to have renal failure Used conservative medication but was not controlled 
15 days back Decrease appetite , vomiting nausea, facial puffiness, pedal edema, Distention of abdomen , decreased Urine output 

• History of past illness :- 

Known history of HTN Since 1 year and on irregular medication (tab nefidinol -10 mg) 
No known history of Asthma, Lymphadenopathy, tb, epilepsy 


• Personal history :- 

Diet :- mixed 
Appetite :- Decreased 
Sleep :- adequate 
Bowel and bladder movements :- irregular 
Micturition :- abnormal 

Habits :-No addictions , beedi stopped 5 yrs back

Family history :- 

Not significant 

• General examination :- 

Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No Pallor
No Icterus
No Clubbing
No Cyanosis
No Lymphadenopathy
Edema of feet -present
No Malnutrition

Vitals:-
Temperature-98.6 F
Pulse rate-88 bpm
RR-32 cycles per min
BP-130/80 mmHg
SPO2-98% at room temperature


SYSTEMIC EXAMINATION:

CVS- 
Inspection :

Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.

Palpation :

S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm lateral to midclavicular line .

Auscultation : 

No cardiac murmurs heard.




Respiratory System- 

Inspection : -

Chest is normal bilaterally symmetrical 
Position of trachea is central 
Movements are bilaterally symmetrical.
No scars , sinuses, or visible pulsations.
BAE+

Palpation :

No local rise of temperature
No tenderness
All inspectory findings are confirmed

Percussion  :-

Resonant sound is heard
Auscultation 
Normal vesicular sounds are heard.


Abdomen: 

Distention of abdomen 
No tenderness
No palpable mass
Liver and spleen not palpable 


CNS :-

Conscious, speech is normal, no neck stiffness and kernings sign negative.
No finger and nose in coordination.


Investigations :- 

2D echo :-


USG ABDOMEN:-



Complete Urine examination :-



ECG 

Haemogram



Blood urea


Serum iron


Serum creatinine


LFT


Serum electrolytes :-



Blood grouping and Rh type :-



X-Ray 









Provisional Diagnosis :-

Chronic kidney disease -On maintainance hemodialysis,Diabetic nephropathy ?

Treatment :- 
Tab nodosis 500mg PO/BD
Tab nicardia. Retard 20 mg PO/BD
Tab shelcal 1 PO/OD 
Fluid restriction less than 1 lit / day 
Salt restriction less than 1.2g per day 
Inj iron sucrose 100 mg to 100ml IV weekly




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