GM case 01.

 General Medicine Case 01

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Date of admission:- 25/07/2021

A 50 year old male who works as a farmer admitted to OPD with complaints of swelling all over body since 10 days, shortness of breath,decreased urine output since 2 days, constipation from 3 days, abdomen distension on and off.

History of Present illness:- 

Patient was apparently asymptomatic since 10 years.He developed edema over face and legs.He admitted in other hospital and diagnosed as Chronic kidney disease and patient underwent 5 session of dialysis.

Patient has pedal edema , face puffiness, shortness of breath, decreased urine output, constipation and admitted to our hospital and undergone 4 dialysis.

Patient is Diabetic and has Hypertension. Patient has pain or decreased pain sensation in legs since 3 years. 

Repeated trauma to legs . Delayed healing.

Patient readmitted on 5/08/2021 due to chest pain.

Past History:-

Patient is Diabetic since 10 years, Hypertension since 4 years . No asthma, no T.B, no epilepsy,no allergies.

History of Epididymectomy 5 years ago.

Personal History:-

Appetite abnormal, Sleep is not adequate, Bladder and bowel movements abnormal .

Mild alcohol addiction. No allergies.

Family History:-

No family member has similar complaints.Patient mother has Hypertension.No history of CAD , asthma , thyroid disorder in family.

Treatment History:-

Patient was undergone treatment for hypertension (drug-- nefidinol) and for diabetes.

General examination:- 

Patient is conscious, lethargic and cooperative.

Paleness- present

Dry skin over legs.

Bipedal pitting Edema.

No lymphadenopathy.

No icterus,no cyanosis,no clubbing.

Mild dehydration.

Vitals:- 

Temperature :- 97°F

Pulse rate:- 80/min

Respiration rate :- 16 /min

Blood pressure:- 140/70 mm Hg

SpO2:- 98% 

Systemic Examination:-

CVS:- Cardiac sounds s1, s2

Cardiac murmurs - No

Respiratory system:- Dyspnoea present

No wheezing

CNS:- Conscious

Normal speech

Abdomen:- Obese, No tenderness,No palpable mass, Liver not palpable, Spleen not palpable.

Investigations:-

Blood urea--68 mg/dl 

Serum creatinine-- 3.2 mg/dl 

RFT:- 

Urea -- 94 mg/dl 

Creatinine-- 3 mg /dl 

Uric acid --6.9 mg/dl 

Calcium--9.6 mg/dl

Phosphorus--4.3 mg/dl 

Sodium--- 135 mEq/L 

Potassium-- 3.5 mEq/L 

Chloride--- 101 mEq/L 

Serum Electrolytes:- 

Sodium--- 132mEq/L

Potassium-- 4.3 mEq/L

Chloride-- 96 mEq /L 

Hemogram:-

Hemoglobin-- 9.8 GM/dl 

Lymphocyte-- 18% 

PCV-- 26.7 vol%

MCV-- 74.6fl

MCH-- 27.4 pg

MCHC-- 36.7 %

RDW- CV-- 12.3%

RDW- SD-- 33.9 fl

RBC Count-- 3.58 millions/ cumm

Platelet Count-- 3.02lakhs/ cumm

Smear count:-

RBC -- microcytic hypochromic

WBC--- normal in limits

Platelet--- adequate

Hemoparasites-- none

Impression --- microcytic hypochromic anemia

ABG:- 

PH-- 7.57

PCO2-- 24.1 mm Hg

PO2-- 35 mm Hg

HCO3-- 22.6 mmol/ L

St.HCO3-- 25.6 mmol/L

BEB--- 1.9mmol/L

BEecf-- 0.6 mmol/L

TCO2 -- 44.6 vol

O2 Sat-- 72.3 %

O2 Count-- 12.1 vol%

Blood sugar

PLBS-- 219 mg/ dl 

 FBS --- 193 mg/dl 

Serum iron -- 71ug/dl 

Glycated hemoglobin:-

HbA1C -- 7.1% 

ECG:- 

Final diagnosis:- 

Chronic kidney disease on hemodialysis. 

Treatment:-  

Inj. LASIX 40 mg IV/BD

TAB. NICARDIA 10 mg PO/TID

TAB. OROFER- XT PO/BD

INJ. Erythropoietin 4000 IU S/C once weekly

TAB. NODOSIS 550 mg PO/BD

TAB. SHELCAL 500 PO/ OD

Fluid restriction upto 1 lit/ day

Salt restriction < 2 gm / day

Discussion:- 

After dialysis why patient still suffer from shortness of breath?

Does there is any relationship between Acute 

epididymitis and CKD ?