General Medicine Case 01

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed, informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

CHIEF COMPLAINT:

A 55 year old male who is a stonemason by occupation came to OPD with chief complaints of swelling in bilateral lower limbs from past 6 months.


HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 6 months back, then he developed pedal edema which was gradual in onset and progressive in nature, non pitting type and extending up to the ankles which was more on right side than left.

No history of fever, weight loss

PAST HISTORY:

The patient is a known case of hypertension and on medication.

History of Hemodialysis-second time + which was unremarkable (29/01/2022)
He had no history of Diabetes mellitus/COPD/Asthma/TB/Epilepsy.

FAMILY HISTORY:

There is no similar complaints in the family.

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Bowel and bladder movements: regular

Socio- economic: poor

Sleep- adequate

GENERAL EXAMINATION:

The patient is conscious, coherent and cooperative and well oriented to time, place and person.

Pallor +

Icterus -

Cyanosis -

Clubbing -

Lymphadenopathy -

Pedal Edema +

Skin- Dry, scaly

Nails- appears brittle

NAILS OF LOWER LIMBS APPEAR BRITTLE

 

 
VITALS:

Temp: afebrile

B.P: 120/70 mm Hg

PR: 90 bpm

RR: 18/ minute

SYSTEMIC EXAMINATION:

CVS

S1 and S2 are heard

no thrills and murmurs

Respiratory

BLAE present

Abdomen

soft, non tender, no organomegaly detected

CNS

conscious and normal speech

normal gait

cranial nerves are intact

motor system is normal

reflexes are normal

INVESTIGATIONS:

COMPLETE BLOOD PICTURE:






ULTRASOUND ABDOMEN:

USG IMPRESSION- BILATERAL POLYCYSTSIC KIDNEYS WITH RENAL PARENCHYMAL CHANGES AND MULTIPLE HEPATIC CYSTS


SERUM CREATININE-



BLOOD UREA:



Serum Electrolytes ( Na, K, Cl ):



Serum Iron:

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on MHD secondary to bilateral polycystic kidney disease with hepatic cysts.

TREATMENT:

Tab Lasix 40mg bd (Furosemide)

Tab Nodosis 500mg bd (Sodium bicarbonate)

Tab Nicardia 10mg bd (Calcium channel blocker Nicardipine)

Tab Orofer-xt 1tab od (Iron supplement)

Tab Shelcal-ct 1tab od (Calcium supplement)

Inj. Erythropoietin 4000 IV S/C (once weekly)

Monitoring vitals