A CASE OF ESRD PRESENTED IN SUMMER 2023
NOTE:
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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 a diagnosis and providing treatment best to our skills and wisdom.
A 55 years old man , daily wager by occupation presented in the casualty with complaints of shortness of breath and pain in lower back.
CHIEF COMPLAINTS
➤ Shortness of breath since 10 days.
➤ Pain in lower back since 5 days .
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1month back , then he developed shortness of breath.
SOB was insidious in onset , Grade II, gradually progressed .
Patient has orthopnea and dyspnea.
He has decreased urine output since 1 month , which is thin stream , poor flow , frothy and has increased frequency , associated with generalised itching .
He also has pain in his lower back which is dull , non radiating and not associated with micturition .
Not associated with cough , cold , fever or chest pain .
HISTORY OF PAST ILLNESS
➤k/c/o diabetes since 10 yrs.
➤k/c/o hypertension since 9 months .
➤k/c/o renal failure since 5 months .
➤Not a known case of bronchial asthma ,epilepsy, tuberculosis.
DRUG HISTORY
➤ Tab Amlong 40mg PO/TID since 1 yr for HTN .
➤ Insulin since 25 yrs for Diabetes .
PERSONAL HISTORY
➤ Occupation : Daily wager
➤Patient is married
➤Patient takes mixed diet but has lost his appetite.
➤Bowel movement is normal and bladder movement is abnormal.
➤Addictions : Alcohol - occasionally
Tobacco - 5 packets/day
➤No allergy
FAMILY HISTORY
➤No significant family history.
GENERAL EXAMINATION
➤Pallor :Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
VITALS
➤Temperature : 98.3℉
➤PR : 102 beats per minute
➤BP : 130/90 mm of Hg
➤RR : 20 cycles per minute
➤SpO2 : 100% in room air
➤Blood Sugar (random) : 97mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all
the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤No tenderness
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : Normal
➤No signs of meningeal irritation
Neck stiffness: no
Kernig's sign : no
PROVISIONAL DIAGNOSIS : CHRONIC RENAL FAILURE (Stage V)
INVESTIGATIONS
1) USG
2) Serum Creatinine
3) Serum electrolytes
4) Complete Urine Examination
5) ECG
6) 2D ECHO
7) HEMOGRAM
8) BLOOD GROUPING
9) LFT
10) BLOOD UREA
11) BLOOD SUGAR RANDOM
TREATMENT
1. Salt restriction (<2g/day)
2. Fluid restriction (<1.5L/day)
3. Tab. Nodosis 500mg/PO
4. Tab. Shelcalc 500mg / PO BD
5. Tab. Bio-D3 PO BD
6. Tab Lasik 40mg PO/BD
7. Tab. Amlong 10mg PO/BD
8. Inj. HAI
