Final exam long case
19/01/2023
Chief complaint :
A 62 year old male patient of resident battugudem, farmer by occupation came to opd with a complaint of decreased appetite, vomiting, nausea, facial puffiness, pedal edema, distension of abdomen and decreased urine output from 15 days.
History of present illnesses:
patient was apparently Asymptomatic 10 years back then he had fever, difficulty in having food and was taken to hospital and incidentally found to have diabetes mellitus and started on conservative management
Patient was asymptomatic 3 years back and he noticed pedal edema, facial puffiness and was not treated for it
And later 2 years back the patient was Unconscious and unable to talk and was presented to local RMP doctor and was diagnosed the condition as renal failure. And conservative treatment but was not controlled. Then he went to government hospital nalgonda.
2years back he was diagnosed as hypertension
15 days back he was suffering from vomitings, nausea, facial puffiness, pedal edema, distention of abdomen, decreased urine output, decreased appetite.
No history of SOB, fever, chest pain, pain abdomen
History of past illness:
Known case of hypertension since 2 year and medication tab. Nicardia 10mg
Known case of diabetis mellitus since 10 years and is on medication.
Not a known case of asthma, tb, epilepsy.
Family history :
Not significant
Personal history :
Diet :mixed
Appetite :decreased
Bowel and bladder movements :irregular
Micturation: normal
Allergies :no allergies
Addictions :no addictions present
5 years back bidi smoking
Daily routine :before 15 days
6:00 wake up
7:30-8:00 breakfast
9:00 went to work ( farmer)
1:30 lunch
6:00 return to home
8-9:00 dinner
10:00 sleep
General examination:
Patient is consciousness, coherent, cooperative and well oriented to time, place.
Patient is moderately built and nourished
Pallor:absent
Icterus:absent
Clubbing:absent
Lymphadenopathy :absent
Pedal edema :present
Vitals :
Bp:170/90mm hg
Temperature : afebrile
Pulse rate :69bpm
Respiratory rate:15 cycles per minute
Systemic examination:
Cvs:
Inspection:
Bilateral symmetrical chest
No visible engorged veins, scars or sinuses on chest
Palpation:
S1 and S2 are heared
No thrills or murmurs
Apex beat present at 5th intercoastal space 2cm lateral to mid clavicular line
Percussion :
Heart borders are appreciated
Auscultation:
No cardiac murmurs heard
Respiratory system:
Inspection:
Chest is normal, bilateral symmetrical
Position of trachea is central
Movements are bilateral symmetrical
No scars, sinuses or visible pulsations
BAE positive
Palpation :
All inspectory findings are confirmed
No local rise of temperature
No tenderness
Percussion:
Right. Left
Supraclavicular Resonant. R
Infraclavicular. R. R
Mammary. R. R
Axillary. R R
Infra axillary. R R
Suprascapular. R R
Interscapular. R R
Infrascapular R R
Auscultation:
Right. Left
Supraclavicular. Normal vesicular NVBS
breathe sounds
Infraclavicular. NVBS. NVBS
Mammary. NVBS NVBS
Axillary. NVBS. NVBS
Infra axillary. NVBS. NVBS
Suprascapular. NVBS. NVBS
Interscapular. NVBS. NVBS
Infrascapular NVBS. NVBS
Abdomen:
Inspection
Shape of the abdomen - distention
Umbilicus - central and inverted
Sinuses and scars - not visible
No dilated veins
Palpation
No local rise in temperature
No tenderness
No palpable mass
No organomegaly
Hernial orifice -normal
Free fluid - no
No bruits
Liver not palpable
Spleen not palpable
Percussion:-
Resonant
Auscultation:-
Bowel sounds heard
CNS:
Patient is conscious , coherent, cooperative and we'll oriented to time and place.
Speech- normal
No sign of meningitis
Motor and sensory system- Normal
Cranial nerves- normal
Memory intact
Investigations :
2D echo
USG abdomen
Complete urine examination
Blood grouping
provision diagnosis:
Chronic kidney disease
Diabetic nephropathy?
Hypertension positive 2 year
Treatment:
Tab Nodosis 500mg po/bd
Tab nicardia retard 10mg po/od
Tab shelcal po/od
Inj iron sucrose 100mg+100ml normal saline iv once in a week
Salt restriction less than 1-2 grms per day
Inj monosef 1grm iv bd
Tab baclofen 5mg po tid
Comments
Post a Comment