50 YEAR OLD MALE WITH SWELLING OF UPPER AND LOWER LIMBS.
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I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis
50 year old male came with complaints of swelling of upper and lower limbs since 5-6months.
HOPI:
Patient was apparently asymptomatic 5-6months back then he developed
- swelling of body, facial puffiness, swelling of hands, swelling of legs- insidious in onset, gradually progressive
- swelling of both lower limbs- pitting type, extending upto knee, aggravated on sitting/walking, relieved on lying down.
-Patient complaints of reduced urine output since 10 days
associated with burning micturition.
- C/O fever since 10 days low grade, intermittent associated with chills and rigors, relieved on taking medication.
-C/O SOB- grade 2 since 10 days, relieved on rest.
-No h/o pain abdomen, abdomen distension, chest pain, palpitations, no orthopnoea, PND.
PAST HISTORY:
K/C/O DM2 since 10 years, on medication( Tab. Metformin 500mg BD)
K/C/O HTN since 5 years, on Tab. Amlodipine 10mg OD
K/C/O Epilepsy since 2 years, on Tab Levipil 750mg OD
K/C/O CAD since 2 years, on Tab Clopidogrel OD
Not a K/C/O TB, CVA, Thyroid disorders, Asthma.
PERSONAL HISTORY:
Diet mixed
Sleep normal
Regular bowel and bladder habits
Alcoholic, stopped 2 years back.
Smoker, stopped 2 years back
No significant family History
GENERAL EXAMINATION:
O/E
Patient is conscious coherent cooperative
Afebrile on touch
PR : 84bpm
RR : 16cpm
BP : 140/80 mm of hg
Grbs :119 mg/dl
SYSTEMIC EXAMINATION:
RS: BAE , NVBS no added sounds
CVS : S1 S2 heard no murmurs
P/A : soft , non tender
CNS : higher mental functions intact
Tone normal in all 4 limbs
Power 5/5 in all limbs
All reflexes present.
INVESTIGATIONS:
Hb- 8.9gm/dl
TLC- 5200cells/cu.mm
PLT- 3.43 lakhs/cu.mm
CUE:
Albumin: present(3+)
Pus cells: 3-4
Epithelial cells: 2-3
RBS: 131mg/dl
Na- 140mEq/L
K- 6mEq/L
Cl-108mEq/L
Ca- 1.20mmol/L
Serum creatinine- 1.7mg/dl
Blood urea- 69mg/dl
USG ABDOMEN:
1. GB wall edema
2. Minimal ascites
3. B/L pleural effusion-S/o polyserositis
4. Grade I RPD changes in B/L kidneys
5. Mild bladder wall thickening? Cystitis.
ECG:
PROVISIONAL DIAGNOSIS:
HYPERKALEMIA SECONDARY TO ?ACUTE RENAL FAILURE.
FEVER UNDER EVALUATION
K/C/O DM2, HTN, CAD.
TREATMENT:
1. INJ HAI S/C premeal /TID
2.Tab. NICARDIA 10mg PO/OD
3.Tab. ECOSPIRIN- AV(75/10) PO/HS
4. Nebulisation with SALBUTAMOL 2 RESPULES
EVERY 4th HOURLY
5. Tab. LASIX 40mg PO/BD.
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