57 year old male with CKD
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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 year old male,who was farmer by occupation, came to OPD with
CHIEF COMPLAINTS :
• Increased abdominal pain since 10 days
• SOB since 10 days
• Unable to speak since 2 days
HOPI:
• Apparently pt was asymptomatic 6 mnths back
• Then he developed puffiness of face, pedal edema, abdominal pain, back ache, fever, burning micturition for which he visited a local hospital.
• He got diagnosed with renal calculi and also shrunken kidneys for which he took medications and got relief.
• Since 10 days, he again developed increased abdominal pain and SOB
• Also couldn't speak from 2 days
PAST HISTORY:
• k/c/o renal atrophy/shrunken kidneys since 6mnths
• NSAID abuse since 20 yrs for stomach ache ( due to bloating and gas as said by the pt)
PERSONAL HISTORY:
• Farmer by occupation
• Appetite lost
• non vegetarian
• Bowel habits irregular
• micturition - burning micturition
• Addictions - beedi since 40 yrs
FAMILY HISTORY :
Nil significant
GENERAL EXAMINATION :
Pallor - present
Oedema of feet - yes
Cyanosis, clubbing, lymphadenooathy, icterus, malnutrition - no
VITALS :
Temp - febrile
PR - 118bpm
RR - 30cpm
BP - 110/80mmHg
SPO2 - 98%
GRBS - 116mg%
SYSTEMIC EXAMINATION :
CVS:
S1, S2 heard
No thrills, no murmurs
RS:
Dyspnoea present
No wheeze
Trachea central
Breath sounds vesicular
No adventitious sounds
P/A:
Distended
No tenderness, palpable mass
CNS:
Conscious
Speech - no response
No signs of meningeal irritation
PROVISIONAL DIAGNOSIS :
AKI ON CKD
INVESTIGATIONS :
29/8/2022
TREATMENT:
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