PATIENT CANE WITH C/O GIDDINESS SINCE 15 DAYS

 Case History and Clinical Findings

C/O GIDDINESS SINCE 15 DAYS

HOPI-

PATIENT WS APPARENTLY ASYMPTOMATIC 15DAYS AGO THEN DEVELOPED EPISODES OF GIDDINESS A/W BLURRING OF VISION A/W SWEATING RELIEVED AFTER TAKING FOOD DAILY ONE EPISODE

H/O CHEST PAIN SINCE 4DAYS PRICKING TYPE ON AND OFF ,NO PRECIPITATING FACTORS

H/O TINGLING AND NUMBNESS OF LOWER LIMBS SINCE 10 YEARS EXTENDING FROM TIP OF TOES TO SHIN OF TIBIA

H/O BURNING SENSATION OF FEET SINCE 5 YEARS

H/O LOOSE STOOLS FOR 1 DAY WHICH WAS ONE WEEK AGO AND SUBSIDED ON MEDICATION FOLLOWED BY PAIN ABDOMEN IN UMBLICAL REGION SINCE THEN

NO H/O LOSS OF APPETITE SINCE 1 WEEK

NO H/O POLYURIA,POLYDIPSIA

NO H/O PALPITATIONS ,SOB

NO H/O HYPOGLYCEMIC EVENT AT NIGHT


NO H/O DECREASED URINE OUTPUT ,BURNING MICTURITION

NO H/O FEVER, PEDAL EDEMA ,FACIAL PUFFINESS

PAST H/O-

K/C/O HTN SINCE 30YRS AND ON T.TELMA AM 40/5

K/C/O DM SINCE 30 YRS ON INJ MIXTARD 20U(BBF)-X-15U(BBF)

K/C/O CKD SINCE 13 YEARS

ON EXAMINATION

PT IS CONSCIOUS, COHERENT,COOPERATIVE

TEMP-AFEBRILE

PULSE RATE 80 BPM

BP 110/80 MMHG

CVS-S1 S2 HEARD NO MURMURS

RS- BAE PRESENT NVB

P/A-SOFT,NON TENDER

OPHTHALMOLOGY REFERRAL I/V/O -DIABETIC RETINOPATHY

IMPRESSION -NORMAL FUNDUS STUDY


PROVISIONAL DIAGNOSIS :-

PERIPHERAL NEUROPATHY (SENSORY &MOTOR)

DIABETES MELLITUS SINCE 30 YEARS

HYPERTENSION SINCE 30 YEARS

CHRONIC KIDNEY DISEASE SINCE 13 YEARS

BENIGN PROSTATIC HYPERPLASIA


Investigation:-

RFT 04-05-2024 04:15:PM :-

UREA37 mg/dl50-17 mg/dl

CREATININE2.6 mg/dl1.3-0.8 mg/dl

URIC ACID6.7 mmol/L7.2-3.5 mmol/L

CALCIUM10.0 mg/dl10.2-8.6 mg/dl

PHOSPHOROUS2.7 mg/dl4.5-2.5 mg/dl

SODIUM137 mmol/L145-136 mmol/L

POTASSIUM4.6 mmol/L.5.1-3.5 mmol/L.

CHLORIDE102 mmol/L98-107 mmol/L

LIVER FUNCTION TEST (LFT) 04-05-2024 04:15:PM :-

Total Bilurubin0.56 mg/dl1-0 mg/dl

Direct Bilurubin0.20 mg/dl0.2-0.0 mg/dl

SGOT(AST)12 IU/L35-0 IU/L

SGPT(ALT)10 IU/L45-0 IU/L

ALKALINE PHOSPHATASE179 IU/L119-56 IU/L

TOTAL PROTEINS6.9 gm/dl8.3-6.4 gm/dl

ALBUMIN4.0 gm/dl4.6-3.2 gm/dl

A/G RATIO1.42

HBsAg-RAPID04-05-2024 04:15:PM:-Negative 

Anti HCV Antibodies - RAPID04-05-2024 04:15:PM :-Non Reactive 

COMPLETE URINE EXAMINATION (CUE) 04-05-2024 04:15:PM:- 

COLOUR:-Paleyellow

APPEARANCEClear

REACTIONAcidic

SP.GRAVITY1.010

ALBUMIN-Nil

SUGAR+++

BILE SALTS-Nil

BILE PIGMENTS-Nil

PUS CELLS-2-3

EPITHELIAL CELLS-2-3

RED BLOOD CELLSNil

CRYSTALS-Nil

CASTS-Nil

AMORPHOUS DEPOSITS-Absent

OTHERS-Nil

POST LUNCH BLOOD SUGAR04-05-2024 04:17:PM:- 196 mg/dl140-0 mg/dl

ABG 05-05-2024 09:12:AM:- 

PH7.33

PCO229.7

PO290.0

HCO315.3

St.HCO317.2

BEB-9.1

BEecf-9.4TCO231.7

O2 Sat96.1

O2 Count15.5

HEMOGRAM:-

HB-11.1

TLC-6700

PLT-2.80

RBC-3.55

HBA1C-7.1 %

FBS-70 MG/DL

PLBS-196MG/DL

SPOT UPCR-

SPOT URINE PROTEIN -6.0

SPOT URINE CREATININE 87.5

RATIO 0.06

2DECHO-

EF-65 %

IVC-0.7CM COLLAPSING

TRIVIAL TR+/AR+ ,NO MR

NO RWMA ,NO AS/MS SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION

GRADE 1 DIASTOLIC DYSFUNTION ,NO PAH/PE/LV CLOT

USG ABDOMEN &PELVIS (06/5/24)

IMPRSSION -B/L GRADE 1 RPD CHAGES IN KIDNEY

B/L RENAL CORTICAL CYSTS

GRADE 1 PROSTATOMEGALY


Treatment Given:-

T.TELMA -AM 40/5 PO/OD

T.DYTOR PLUS 10/25 PO/OD

T.PREGABALIN 75MG PO/HS

T.ECOSPORIN AV 75/10 PO HS

T.PAN 40MG PO/OD

INJ HAI S/C TID ACC TO GRBS

T.SHELCAL -XT PO/OD

TAB.NODOSIS 500MG PO/OD

Comments

Post a Comment

Popular posts from this blog

My experience with general cellular pathology in a case based blended learning ecosystem’s CBBLE

  WARM REGARDS, I'm shivani tunia, a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you. Together, let's delve into the captivating world of patient care, where every interaction holds the potential for learning, growth, and making a positive impact on the lives of those we serve. Thank you for joining me on this incredible journey! CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONL...
Read more

70 YEAR OLD FEMALE WITH FEVER AND LEFT SIDED PAIN

Image
 T.shivani   MBBS 9th semester Roll no:06 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .   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 diagnosis . Following is the view of my case.. 70 yr old female with fever and left sided chest pain . January 11, 2022 A 70 year old female came to casuality on 05-01-2022 with...
Read more

A 55 YEAR OLD PATIENT WITH FEVER CHEST PAIN AND LOSS OF APPETITE

Image
January 01, 2023   A 55 years old patient presented with fever, chest pain and loss of appetite This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"  - 55  year old male,  -farmer by occupation,   -came to Medicine OPD with complaints of :-  —>  Chief Complaints: -( Fever since 13 days , chest pain since 10 days, and loss of appetite since 10 days ) -History of present illness:- —>Patient was apparently asymptomatic 8 months ago then he developed fever , cough, shortness of breath on exertion fever is of h...
Read more