62 yrs male with generalized body swelling and scrotal edema

A 62 year old male came to casuality with chief complaints of 

Generalized body swelling since 15 days 
Facial puffiness since 15 days 
Scrotal swelling since 15 days 


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2years ( July 2021)  back, then developed weakness of right upper and lower limb associated with slurring of speech and deviation of mouth for which he was taken to hospital and diagnosed as right hemiparesis .

10 months back developed B/l  lower limb edema ( pitting type), upper limb edema and facial puffiness for which was managed conservately . 

15 days back again developed generalized body swelling, facial puffiness,sob and scrotal swelling .  



PAST HISTORY 

K/c/o hypertension since 1 yr and on T. Clinidipine 10 mg and furosemide 40mg .

K/c/o CVA with right hemiparesis 2 yrs back.  

Not a k/c/o DM .

PERSONAL HISTORY 

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- regular 


Habits/Addiction: chronic alochol and smoker for 40 yrs 


FAMILY HISTORY 

not significant 

VITALS

Vitals @ Admission:

BP: 130/90 mmHg

HR: 88

RR: 16cpm

TEMP: 98.6

SpO2: 98%

GRBS:116mg%

General Examination:

Pallor - present 
Icterus - no 
Cyanosis- no
Clubbing -
Lymphadenopathy - no
Oedema of feet - present 


Systemic Examination:
CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS:  

Higher function test: 


Slurred speech  

Orientated to time place person.

Memory : Intact 





INVESTIGATIONS 
ON DAY OF ADMISSION (22/06/2022) 

HEMOGRAM:
Hemoglobin: 4.8 g/dl
TLC: 4000cells/cumm
Platelet: 1.20

ELECTROLYTES:
Na: 136
Cl: 108
K: 4.6


RENAL FUNCTION TESTS
Urea: 136
Creatinine: 10.6



ON 30/06/2022

HEMOGRAM:
Hemoglobin: 5.1 g/dl
TLC: 4300cells/cumm
Platelet: 1.35

RENAL FUNCTION TESTS
Urea: 158
Creatinine: 11.7
Phosphorus - 5.8




Provisional Diagnosis: 
CKD

Treatment:



Comments

Post a Comment

Popular posts from this blog

A case of 36 yrs old male with CKD came for regular dialysis

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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. Leela Vamsi Roll no 23 A 36 yrs old male patient presented to the opd 1 yr back with complaints of pedal edema, facial swelling and sob . Now came for maintenance dialysis. History of present illness. A 36 yrs ...
Read more

71 yrs old male with b/l pedal edema

Image
 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 Cheif complaints     Bilateral pedal oedema since 4 days  SOB - since 4 days  ( grade 2)   Reduced urine output - since 4 days  History of present illness  Patient was apparently asymptomatic 2 years ago then developed loin pain , pedal edema and facial puffiness,  after then he went to hospital and diagnosed as renal disease which progressed even after medication . After that due to failing of kidney he had undergone for dialysis - 1 yr ba...
Read more