GENERAL MEDICINE CASE

             

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            A 52 yr old male resident of Mothkur, farmer by occupation came to the OPD with chief complaints of shortness of breath , and swelling on both legs and there was decreased urine output .

History of Present illness : 

     Patient was apparently asymptomatic 1 month back . Then he complained of bilateral pedal edema which was gradually progressive pitting type . He also complained of decreased urine output . This caused him great disstress and considerably decreased his apetite . He went to nearest hospital on 11 -07 -2021 where he finally diagnosed with CKD on MHD , Diabetic nephropathy and Hydrocoel . He underwent 5 sessions of  dialysis on  15-07-2021 , 17-07- 2021 , 19 -07-2021 , 21-07-2021 ; 23-07-2021 . 

5 days back patient came to casuality with swelling in legs ,chest pain and undergone 4 dialysis. 

PAST HISTORY : 

  ●Patient was known case of diabetes mellitus type 2  from past 10 years.

● Patient  was also known case of Hypertension from past 4 years 

● Pateint was undergone  surgery 5 years back due to swelling of scrotum, occurs as a result of  fluid collected in thin sheath surrounding a testicle.

● Patient was known case of CKD on MHD 

● Not a known case of epilepsy ,TTS 

PERSONAL HISTORY : 

• Micturition abnormal 

• Decrease apetite 
• No adequate sleep 
• Mixed diet 
• No smoking addiction 
• Regular alcohol addiction 
• Bowel and bladder movements are irregular.  

FAMILY HISTORY: 

● There is no case of such illness seen in her family members 
● There is no history of Hypertension and diabetes in the family . 

TREATMENT HISTORY: 

• Patient is undergoing drug therapy for diabetes and hypertension 
• He is taking insulin for daibetes since 9 years 
• Presently he is taking Nefidinol of 25mg for hypertension 
• No known allergy for drugs 

GENERAL EXAMINATION: 

• Patient is consious coherent and cooperative 
• There is pedal edema 

• No cynosis  No clubbing and No lymphadenopathy. 



Vitals : 

 • Pulse rate - 98bpm 
•Blood pressure - 160/100 
• Respiratory rate - 8cpm 
• SpO2 at room air - 98% 
• Temperature -  Afebrile 

SYSTEMIC EXAMINATION: 

1. Cardiovascular system: 

• Thrills - No 
• Cardiac sounds - S1 and S2 heard 

2. Respiratory system: 

• Dyspnea - present 
• No wheezing
•  Position of trachea - central 
• Bilateral air entry + 
• Normal vesicular breath sounds - heard 

3. Abdomen : 

• Shape of abdomen - obese 
• No tenderness 
• No palpable mass 
• Liver and spleen are not palpable 

4. Central nervous system: 

• Patient is conscious 
• Speech - Normal 
• Sensory and motor reflexes - intact 
• No signs of meningeal irritation 

FINAL DIAGNOSIS : 

• Chronic kidney disease on maintenance hemodialysis . 
•Hypertension and Type 2 diabetes mellitus

INVESTIGATION:

 RFT : 
Urea : # 94mg/dl 
Creatinine : #3.0mg /dl 
Uric acid : 6.9mg / dl
Calcium : 9.6mg/dl 
Phosphorus: 4.3mg /dl 
Sodium : #135 mEq / L 
Pottasium : 3.5 mEq / L 
Chloride: 101 mEq/ L 

Fasting blood sugar : #193mg/dl 

Post lunch blood sugar : #219mg/dl 

Serum Iron : 71ug/dl 

Glycated haemoglobin: HbA1c- 7.1% 

Hemogram :

Haemoglobin : #9.8 gm/dl 
Total count : 8700 cells / cumm 
Neutrophils : 73%
Lymphocytes : #18% 
Eosinophils : 04% 
Monocytes : 05% 
Basophils : 00% 
PCV : #26.7vol% 
MCV : # 74.6 fl 
MCH : 27.4 pg 
MCHC : # 36.7 %
RBC count : 3. 58 millions / cumm 
Platelet count : 3.02 lakhs / cumm 

Smear : 

RBC - Microcytic hypochromic 
WBC - Within normal limit 
Platelets - Adequate 
Hemoparasites - No hemoparasties seen 
Impression - Microcytic hypochromic Anemia 

ECG 

Ultra sound report form : 


Treatment : 

INJ. LASIX 40mg IV / BD 
TAB. NICARDIA 10mg PO / TID 
TAB. OROFER - XT PO /BD 
INJ. ERYTHROPOIETIN 4000IU S/C once weekly 
Tab. SHELCAL 500mg PO / OD 
Tab. NODOSIS 550mg PO / BD 
Fluid restriction upto 1Lit / day 
Salt restriction <2gm / day 

DISCUSSION :

1 . What is the sudden causeof renal failure ? If it is due to daibetes then when did it  actually started failing as patient was diabetic since 10 years  ? 

2. Why do most CKD cases have hypertension? 

3. Cant we early diagnosis CKD ? 













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