46 YEARS OLD MALE WITH DIABETIC NEPHROPATHY, CHRONIC KIDNEY DISEASE ON MAINTENANCE ON HEMODIALYSIS
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MEDICINE CASE DISCUSSION:
I've been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
VIEW OF THE CASE :
46 years old male, who is tailor by occupation came with the cheif complaints of shortness of breathe since one week, Pedal edema upto knee since one month with facial puffiness and upper limb edema.
HISTORY OF PRESENT ILLNESS:
Patient came with the complaints of shortness of breathe since one week which is of grade 4 and associated with profuse sweating.
He complaints of pedal edema up to the knee since one month which is of pitting type. He had similar edema episodes before this one month whuch were resolving and reappearing and this time it is not resolved for 1 month. He also developed facial puffiness and upper limb edema.
PAST HISTORY:
He was diagnosed as diabetic 12 years back and on medication.
He was diagnosed as hypertensive 3 years back and on medication.
He is not a known case of Tuberculosis, Asthma, epilepsy
TREATMENT HISTORY:
He is on GLICLAZIDE, VOGLIBOSE AND NICARDIA for control of diabetes and hypertension.
He was underwent 3 sittings of PRP (PAN RETINAL PHOTOCOAGULATION).
He was on hemodialysis treatment. 1st session was done on 8th October 2021, 2nd session on 9th October 2021, 3rd session on 11th October 2021 and 4th session on 13th October 2021
PERSONAL HISTORY:
Appetite- decreased appetite from the onset of shortness of breathe
Diet- mixed
Bowel habits- regular
Bladder habits- regular
Sleep- disturbed
Addictions- he consumed alcohol for 20 years and stopped for last 4 years
Allergies- no allergies
FAMILY HISTORY:
Father of the patient was diet with kidney failure.
GENERAL EXAMINATION:
Conscious, coherent and cooperative
Well oriented to time, place and person
Moderately built and moderately nourished
Pallor- PALLOR PRESENT (severe)
Icterus- No icterus
Cyanosis- No Cyanosis
Clubbing- No clubbing
Generalised lymphadenopathy- No generalised lymphadenopathy
Pedal edema- BILATERAL PEDAL EDEMA UPTO KNEE
VITALS:
On 18.10.2021
Temperature - afebrile
Pulse rate-90 bpm
Respiratory Rate- cycles per minute
Blood Pressure- 140/90 mm of Hg
GRBS-
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:
first and second heart sounds heard and no murmurs
RESPIRATORY SYSTEM:
Bilateral air entry present,
central trachea. Normal vesicular breath sounds.
CENTRAL NERVOUS SYSTEM: higher motor functions normal
PER ABDOMEN EXAMINATION:
Soft and non tender abdomen
INVESTIGATIONS:
HEMOGRAM:
BLOOD GROUP TESTING:
COMPLETE URINE EXAMINATION:
SEROLOGY:
SERUM IRON:
RENAL FUNCTION TEST:
CHEST X RAY:
ELECTROCARDIOGRAPHY:
ULTRASOUND ABDOMEN:
DIAGNOSIS:
DIABETIC NEPHROPATHY, CHRONIC KIDNEY DISEASE ON MAINTENANCE ON DIALYSIS
TREATMENT:
- TAB. LASIX 40mg PO BD
- TAB. GLICLAZIDE 50mg PO BD
- TAB. VOGLIBASE 0.2mg PO BD
- TAB. MET XL 25mg PO OD
- TAB. NICARDIA 10mg PO OD
- TAB. OROFER XT PO BD
- TAB. PAN 40mg PO OD
- TAB. NODOSIS 50mg PO BD
- INJ. ERYTHROPOIETIN WEEKLY
- TAB. AUGMENTIN 62mg PO TID
- TAB. AZITHRO 500mg PO/OD
- SYRUP. BENADRYL 5ml PO TID
- TAB. LEVOCETRAZINE 5mg PO BD
- TAB. PCM 650mg PO SOS
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