Case History -5



 In this online e-logbook, we upload our patients de-identified health data shared after taking his/guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from an available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence-based inputs


A 48 yrs old male patient presented to OPD with complaints of shortness of breath and swelling all over the body.


History of present illness:

Patient was apparently well and asymptomatic 6 years back and  was diagnosed with diabetes following  hypertension which was diagnosed 2 years back and later diagnosed with hypothyrodism 6months back 

Patient also was diagnosed with diabetic nephropathy  along with hypothyroidism.


History of past illness: 

Patient is diabetic since 6years ago and hypertensive since 4 years and hypothyroidism since 6months.

Patient had anasarca.

No history of asthma, epilepsy , tuberculosis .

No history of any sugery or chemotherapy or radiation therapy.


Personal history:

Diet:mixed

Appetite: normal

Bladder and bowel movements: regular

Sleep pattern: adequate

Addictions:Used to consume alcohol stopped from the onset of condition. No smoking.


Vitals:

Temperature:98.4F

B.P.:160/90 

R.R.:18CPM

SPO2%:98

GRBS:124mg%


Systemic examination:

No pallor,icterus,cyanosis, lymphadenopathy,oedema.


Local examination:

CVS:

S1&S2 Heard


No murmurs

CNS: 

Patient was conscious, coherent, cooperative.

Normal Speech.

GIT:

Abdomen: scaphoid

Not tender 

No palpable masses

Liver and spleen:not palpable

 






Investigations

Serum iron:41ug/dl (61-157)


Serum electrolytes:


Na:133mEq/L(136-145)


K:3.7mEq/L(3.5-5.1)


Cl:86mEq/L(98-107)


Serum creatinine:5.9mg/dl(0.9-1.3)


Blood urea:59mg/dl(12-42)


Anti-HCV antibodies:non reactive


Anti-HBs antibodies:non reactive


HIV 1/2 Rapid test:non reactive


Complete blood picture:


Hemoglobin:6.3gm/dl(13.0-17.0)


Total count:15300cells/cumm(4000-10000)


Neutrophils:77%(40-80)


Lymphocytes:15%(20-40)


Eosinophils:1%(1-6)


Monocytes:07%(2-10)


Basophils:00%(0-2)


Platelet counts:4.26lakhs/cumm(1.5-4.1)


Smear: Normocytic normochromic anemia with leucocytosis


Complete urine examination:


Colour:pale yellow (pale yellow)


Appearance:clear (clear)


Reaction :acidic (5.0-9.0)


Specific gravity:1.010(1.001-1.035)


Albumin:++(negative)


Sugar:++++(negative)


Bile salts:nil(negative)


Bile pigments:nil(negative)


Pus cells:4-6HPF(0.5HPF)


Epithelial cells:2-4HPF(0.5HPF)


Red blood cells:nil(0.2 HPF)


Crystal casts:nil(nil)


Amorphous deposits:absent(nil)


Others:nil 


Provisional diagnosis:CKD on MHD


Treatment:

1. Fluid restriction<1.5/day

2.salt restriction<2gm/day

3.T.lasix 40mg PO/BD

4.T.Nicardia 20mg PO/BD

5. T.met xl 25mg PO/BD

6.T.thyronorm 50 MCG PO/BD

7. T.Urogen PO/BD

8. Inj actrapid







 

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