Final Practical Short 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 60 year old male patient driver by occupation came to causality with chief complaints of Pedal edema since 20 days  , vomitings since 1 week , fever since 10 days , Shortness of breath since 7 days , decreased urine output since 5 days .

History of Present Illness 

 Patient was apparently asymptomatic 15 days back then he developed pedal edema in his lower limb which is pitting type fever which is continuous associated with cough and vomiting  since 5days.vomiting of one episode which is non projectile. Cough with sputum which  is red in colour and reduced after medication.

-SOB of grade 4 since 5 days

- After  completion  of (6) session of dialysis he has gone through acute ischaemic stroke.

Past history : 

He had a H/o giddiness 15 years back for which he went to hospital and diagnosed with diabetes and he discontinued medication since 6 years.

-He had H/o TB 15 years back

-Diagnosed wit hypertension since 2 years.

Personal history: 

Diet -mixed

Sleep - adequate

Appetite- Normal

Alcoholic since 30 years.

Family history: 

No similar history in the family 

General examination: 

Patient was conscious, coherent, not well cooperative

Pallor present 

-No cyanosis, clubbing, lymphadenopathy.

- pedal oedema which is pitting type.

Vitals;

Temperature -99.6 F

-B.P-140/80mm Hg

PR-85bpm

RR-26cpm

GRBS -237mg

Systemic Examination:

CVS S1S2+

RS -BAE +

Per abdomen - soft, nontender

CNS -No abnormalities detected

Investigations : 

Complete blood picture : 

Hb- 7.1gn/dl

TLC- 12,500

Lymphocytes -13

PCV -21.6

MCH- 22.7

RBC count- 3.13 million /cumm

RFT : 

Urea-132 mg /dl

Creatinine -10.1 mg/dl

Phosphorus -6.6 mg /dl

LFT :

Total bilirubin -0.76

ALP - 141

Total protein -5.8 gm/dl

Albumin -2.7 gm/dl

Diagnosis : 

Diabetic Nephropathy 

Treatment : 

Salt restriction-<2.4 gm/day

Fluid restriction <1 lit/day

Tab lasix 40 mg

Tab SHELCAL 500 mg.