A 47yrs old patient came with chief complaints of decreased urine output and anasarca since 5 days


28th November , 2021.                



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A 47yrs old patient came with chief complaints of decreased urine output and anasarca since 5 days


Lakshmi Manvitha Yechuri
Roll no:169 

A case discussion of Decreased urine output and anasarca since 6 days. 

I've 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 a diagnosis and treatment plan.     


CASE PRESENTATION

Chief complaints 

Pedal edema , facial puffiness since 6 days 

Shortness of breath since 6 days increased since 3 days 

Decreased urine output since 3 days 


HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 8 years back 

8 years ago on regular checkup found to be hypertensive 

6 years ago complaint of generalised weakness , weight loss diagnosed to be diabetic 

5 years ago he had acute pancreatitis 

6 days back patient developed pedal edema , progressed gradually associated with facial puffiness 


Decreased urine output since 6 days , shortness of breath since 6 days grade 2 to 3 progressed to grade 4 since 3 days  associated with orthopnea , PND , decreased appetite 


No history of fever ,cold , cough , burning micturation , chest pain , giddiness , palpitations


PAST HISTORY  

Diabetes , put on Tab. Glimi M2 PO BD since 6 years 

Hypertension, put on Tab. Omesartan 20  OD since 8 years 

History of acute pancreatitis 5 years ago


PERSONAL HISTORY:

Diet         : Mixed 

Appetite :  Normal 

Sleep      : Adequate 

Bowel and bladder : Regular 

Micturition : Normal 

Addictions:

alcohol stopped 5 years ago 

smoking stopped 5 years ago


FAMILY HISTORY:

Not significant.


GENERAL EXAMINATION: 

Patient is conscious cooperative coherent 

well oriented to time place person and moderately built and moderately nourished                   

pallor present 

no icterus 

no cyanosis 

no clubbing 

Pedal edema present

no lymphadenopathy 


VITALS: 

Temperature: 98.2F 

Pulse rate -95 bpm

Respiratory rate - 26 cpm 

Bp: 180/100mmHg





SYSTEMIC EXAMINATION:

Cardiovascular system : S1, S2 is heard. No murmurs are heard.

Respiratory system : 

BAE present , crepitus present  

CNS : intact

Per Abdomen : Soft, distended,


Clinical images 








INVESTIGATION: 

Complete urine examination 






Hemogram





Colour Doppler 2D echo 





Ultrasound report 






Urine protein creatine ratio 






Serum electrolytes 






ABG






Renal function test 






Serum creatinine 






Liver function test 





Blood urea





Blood sugar random 




ECG 



Anti HCV antibody





HIV 1/2 rapid test 





HBsAg rapid test 



PROVISIONAL Diagnosis 

Chronic kidney disease with type 2 diabetes Mellitus with diabetic nephropathy


TREATMENT

Fluid retention 
diet / salt restriction 
injection lasix gowg (iv/TID) 
tab pan 40mg/PD/OD 
Tab Clinidiptine 10mg/PO/OD 
inj HAI 
strict IO charting 
daily weight monitoring
 tab nodoris 500mg/PD/TID
tab metolazole 5mg/PD/OD
Tab PCM 650mg PO/TID 
Tab ASCORIL-D 15 ml PO/TID




I would like to thank Dr.Rakesh Biswas sir(H.O.D,General Medicine) for giving me this opportunity 




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