General medicine final practical examination - long case
February 9 th, 2022
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Date of administration : 2-2-2022
A 60 yr old male patient driver by occupation came to the opd with chief complaint of
Pedal edema since 5 days
SOB : since 5 days
Fever: since 5 days
Decreased urine out put since 3 days
He is a known case of chronic renal failure & he is on hemodialysis & he underwent (4) sessions of hemodialysis
History of present illness :
Patient was apparently normal 15 days back and he is completely normal & he can able to do his regular routine work. But 15 days back he developed edema in his lower limb which is extended upto ankle which is pitting type
Fever which is continuous associated with cough & vomiting since 5 days. Vomiting of one episode which is non projectile. Cough with sputum which is red in colour and reduced after medication
SOB of grade 4 since 5 days
After completion of (6) session of dialysis he has gone through acute ischaemic stroke.
Past history :
He had a H/O giddiness 15 years back for which he went to hospital and diagnosed with diabetes and he discontinued medication since 6 years back. He had H/O TB 15 years back which is treated with HRZE regime.
Diagnosed with hypertension since 2 years
Personal history :
Diet : mixed
Appetite : normal
Sleep : adequate
Alcoholoc since 30 yrs
Family history:
No relevant family history
General examination:
Patient was conscious, coherent not well cooperative
Pallor
No Cyanosis , clubbing, lymphadenopathy
Pedal edema which is pitting type
Vitals :
Temperature :99.6F
BP:140/80mm Hg
PR: 85bpm
RR:26cpm
GRBS :237 mg
Systemic examination :
CVS :S1 &S2 +
RS :BAE +
PA :soft, non tender
CNS :NAD
Investigations :
ECG :
Hb-7. 1 gn/dl
TLC-12, 500
Lymphocytes -13
PCV -21. 6
MCH -22. 7
RBC count -3. 13 million/cumm
RFT:
Urea:132mg/dl
Creatinine -10. 1 mg/dl
Phosphorus- 6.6mg/dl
LFT:
Total bilirubin -0. 76
ALP -141
Total protein :5.8gm/dl
Albumin :2.7 gm/dl
Complete urine culture :
Mid brain :
It confirms that there are a few infarcts in right corona radiata. Age of infarcta is 12 to 16 hrs
Provisional diagnosis:
CKD on MHC
Final diagnosis :
Diabetic NEPHROPATHY
Treatment:
Salt restriction-<2.4 gm/day
Fluid restriction :<lit/day
Tab lasix 40 mg
Tab SHELCAL -500 mg
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