general medicine case 3

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I have 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 and treatment plan.

A 48 yrs old male patient presented to OPD with complaints of shortness of breath and swelling all over the body.

History of present illness:

Patient was apparently asymptomatic 6 years back and had  was diagnosed with diabetes and following 2 years later was diagnosed with hypertension and is found to suffering from hypothyrodism 6months back 

Patient was having diabetic nephropathy on examination when diagnosed with hypothyroidism.

 

History of past illness: 

Patient is diabetic since 6years ago and hypertensive since 4 years and hypothyroidism since 6months.

Patient had anasarca.

No history of asthma, epilepsy,surgery.

Personal history:

Diet:mixed

Appetite: normal

Bladder and bowel movements: regular

Sleep pattern: adequate

Addictions: No habit of smoking.Used to consume alcohol stopped from the onset of condition.

Vitals:

Temperature:98.4F

B.P.:160/90 

R.R.:18CPM

SPO2%:98

GRBS:124mg%

Systemic examination:

No pallor,icterus,cyanosis, lymphadenopathy,oedema.

Local examination:

CVS:

S1&S2

https://youtube.com/shorts/n3tFuNe1k64?feature=share

No murmurs

CNS:

Patient was conscious, coherent, cooperative.

Normal speech.

GIT:

Abdomen: scaphoid

Not tender 

No palpable masses

Liver and spleen:not palpable

 

Provisional diagnosis:

Diabetic nephropathy

Investigations

Serum iron:41ug/dl (61-157)

Serum electrolytes:

Na:133mEq/L(136-145)

K:3.7mEq/L(3.5-5.1)

Cl:86mEq/L(98-107)

Serum creatinine:5.9mg/dl(0.9-1.3)

Blood urea:59mg/dl(12-42)

Anti-HCV antibodies:non reactive

Anti-HBs antibodies:non reactive

HIV 1/2 Rapid test:non reactive

Complete blood picture:

Hemoglobin:6.3gm/dl(13.0-17.0)

Total count:15300cells/cumm(4000-10000)

Neutrophils:77%(40-80)

Lymphocytes:15%(20-40)

Eosinophils:1%(1-6)

Monocytes:07%(2-10)

Basophils:00%(0-2)

Platelet counts:4.26lakhs/cumm(1.5-4.1)

Smear: Normocytic normochromic anemia with leucocytosis

Complete urine examination:

Colour:pale yellow (pale yellow)

Appearance:clear (clear)

Reaction :acidic (5.0-9.0)

Specific gravity:1.010(1.001-1.035)

Albumin:++(negative)

Sugar:++++(negative)

Bile salts:nil(negative)

Bile pigments:nil(negative)

Pus cells:4-6HPF(0.5HPF)

Epithelial cells:2-4HPF(0.5HPF)

Red blood cells:nil(0.2 HPF)

Crystal casts:nil(nil)

Amorphous deposits:absent(nil)

Others:nil 

Provisional diagnosis:CKD on MHD

Treatment:

1. Fluid restriction<1.5/day

2.salt restriction<2gm/day

3.T.lasix 40mg PO/BD

4.T.Nicardia 20mg PO/BD

5. T.met xl 25mg PO/BD

6.T.thyronorm 50 MCG PO/BD

7. T.Urogen PO/BD

8. Inj actrapid

Follow up:

Patient was asked to visit for every 3 days for dialysis sessions.

Prognosis:

1.Patient was normal and got discharged and was asked to visit for regular dialysis sessions. 

2.He started developing productive cough when there was and delay in his dialysis session but the cough used to get relief after his dialysis session.

3. The patient is again admitted to CKD ward and was taken to AMC for shortness of breath and brought back to CKD for observation.