General medicine case 4
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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 56 years old male patient presented to emergency with a compliant of shortness of breath since 4months.
History of present illness:
Patient was apparently asymptomatic 4 months back and developed bilateral lower limb swelling ,reduced urine output, abdominal distension and scrotal swelling.
Pedal edema pitting type grade 1and developed to grade 2 10 days later and to grade 3 15 days later.
He first developed sweeling in the lower left limb extending upto ankle and right lower limb extending upto thigh.
No complains of loose stool, burning micturition, vomiting,hematuria.
History of past illness:
Patient gives history of pulmonary koch 22yrs back and used ATT for 6months.
Known case of hypertension since 3 months and on medication.
No history of diabetes, epilepsy, surgery.
Personal history:
Appetite: normal
Diet:mixed
Bowel and bladder movement:regular
Sleep pattern:normal
Occasional alcohol consumption.
Family history:
No similar resemblance in any of the family members
Drug history:
Not allergic to any of the known drugs.
Systemic examination:
Patient was conscious, coherent and cooperative.
Moderately bulit and moderately nourished.
No signs of pallor, cyanosis,icterus, lymphadenopathy.
Vitals
Temperature:98.6F
P.R.:98bpm
B.P.:160/90
R.R.:20cpm
SpO2:98%
Local examination:
CVS:
S1 and S2 sounds heard.
Respiratory system:
BAE:+ NVBS:+
Abdomen:
Shape: distended
Liver and spleen non palpable
Provisional diagnosis:CRF with hypertension.
Investigations:
Ferritin-415 ng/ml
Blood urea-164 mg/dl
Serum creatinine-8.7 mg/dl
HIv 1/2 rapid test- non-reactive
Anti HCV antibodies- non-reactive
FBS- 105 mg/dl
Serum iron- 80ng/dl
Serum electrolytes:
Na+ - 143mEq/L
K+ - 4.7mEq/L
Cl- - 98 mEq/L
P - 7.8 mg/dl
Ca - 8.7 mg/dl
HBsAg-rapid - negative
Complete blood picture:
Hemoglobin - 7.7 gm/dl
Total count - 5,900 cell/cumm
Neutrophils - 60%
Lymphocytes - 28%
Eosinophils - 2%
Monocytes - 10%
Basophils - 0%
Platelet count - 4.02 lakh/cumm
Smear - Normocytic normochromic anemia
Liver function test:
Total bilirubin - 0.62 mg/dl
Direct bilirubin - 0.20 mg/dl
SGOT(AST) - 10 IU/L
SGPT(ALT) - 10 IU/L
Alkaline phosphatase - 162 IU/L
Total protein - 4.3 gm/dl
Albumin - 2.0 gm/dl
Hemogram
Hemoglobin - 7.8 gm/dl
Total count - 9,700 cell/cumm
Neutrophils - 88%
Lymphocytes - 09%
Eosinophils - 01%
Monocytes - 02%
PCV - 23.8vol%
MCV - 88.1fl
MCH - 28.9 pg
MCHC - 32.8%
RDW-CV - 13.8%
RDW-SD - 45.6%
RBC count - 2.70 millions/cumm
Platelet count - 3.18 lakh/cumm
Smear:
RBC - Normocytic normochromic
WBC - within in normal limits with relative neutrophilia
Platelet - adequate
Hemoparasites - no hemoparasites detected
Impression - Normocytic normochromic anemia with relative neutrophilia blood picture.
SAAG- 1.8
Ascitic albumin-0.5
Fluid cell count- 25 cells (98@% lymphocytes)
CYTOLOGY- No malignant cells
Blood transfusion: 1 prbc done today along with dialysis
Recent dialysis 25 11 with UF 4000ml
Pre dialysis wt- 67kgs
Post dialysis- 63.5kgs
Diagnosis:
Chronic renal failure
Treatment:
1. Fluid restriction<1.5lit/day
2. Salt restriction<2gm/day
3. T.Amlong 5mg PO OD
4. T Lasix 40mg PO OD
5. T Pan 40 mg PO OD
6. T Shelcal PO OD
7. T Dolo PO SOS
8. T calsoft/Bio D3 plus PO OD
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