1601006102 : GM Long Case

 

CASE OF A 65 YR OLD MALE WITH CKD : LONG CASE GM (1601006102)

 

CASE OF A 65 YR OLD MALE WITH CKD : LONG CASE GM FINALS

1601006102

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This is the case i have been given :

A 65 year old male who was a farmer came to the OPD with

 CHIEF COMPLAINTS OF :

1. Decreased urine out since 4 months

2. Bilateral pedal edema since 4 months and 

3. Abdominal distension since 4 months

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic 4 months back then developed decreased urine output , which is insidious in onset with decreased frequency and later facial puffiness followed by bilateral pedal edema , pitting type, gradually progressed to involve abdomen with abdominal distension he was admitted to the local hospital where he was diagnosed as acute kidney injury , no aggregating and relieving factors. 

There is history of pruritus and pigmentation of both the lower limbs

PAST HISTORY : 

He was k/c/o HTN since 5 yrs and was on medications

No h/o suggesting DM, CAD, CVA, TB, asthma, epilepsy

10 yrs back patient had a road Traffic accident for which surgery(? Intramedullary nail insitu) was done for ?hip fracture In nalgonda govt hospital. He had taken NSAIDS for 1 year then.

1 year back patient gives history of taking NSAIDS 3 tabs per day daily for bilateral knee and back pain given by RMP. He took it daily for 1 year

Patient also gives a h/o bilateral Tympanic membrane perforation 6 yrs back (following an infection).

He gives a history of cataract surgery for right eye 10years ago

FAMILY HISTORY : 

No k/c/o HTN,DM,TB, asthama,CAD, epilepsy and CKD

PERSONAL HISTORY :

Mixed diet

Appetite is reduced

Sleep is adequate

Bowel regular

Oliguria since 4 months

Addictions :  h/o beedi smoking 4-5 years ,stopped 1 year back

GENERAL EXAMINATION :

• Patient is conscious, coherent & cooperative 

• Thin built and malnourished

GENERAL SIGNS :

• PALLOR present

• No Icterus, cyanosis,clubbing koilonychia and Lymphadenopathy 

PEDAL EDEMA + , which is pitting type

VITALS :

• Temp: 98.5 F,

• RR : 18 cycles/min,

• BP : 100/70mmHg,

• PR : 80/min, regular rythm, normal volume,no radio-radial or radio-femoral delay, Condition of the vessel wall is normal

• SpO2: 97% on RA

SYSTEMIC EXAMINATION :

• CVS: s1 s2 +

 no murmurs

• RS:

Bilateral air entry present

Normal vesicular breath sounds, No added sounds

• CNS:

All higher motor functions are normal

Except 8th nerve (Bilateral sensory neural hearing loss present). All other Cranial nerves are intact

Sensory system normal

Motor system normal

Cerebellar signs normal

No meningeal signs

• Per abdomen :

Soft

Non tender

No organomegaly

Bowel sounds heard

INVESTIGATIONS :

Complete blood picture

Complete urine examination

Serum iron

Renal function tests

Liver function tests

Blood grouping & Rh typing

HIV

HbsAg

Anti HCV Antibodies

SARS COVID

USG

ECG 

PROVISONAL DIAGNOSIS:

CKD stage II, secondary to NSAID abuse

TREATMENT GIVEN :

The patient was on hemodialysis along with drugs

Hemodialysis chart

Fluid & salt retention (< 1 litre/day and <2gm/day )

Tab. Nicardia 10 mg TID

Tab. Lasix 40 mg BD

Tab. Nododis 500 mg BD

Tab. Celcol OD

CAP - alpha -D3 OD

Sodium bicarbonate

Injection iron sucrose 100 mg BD

Injection Monocef 1g BD

Injection erythropoietin 4000 iu/ one weekly