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

Image
  43year old male came with the      chief complaints of  Fall due to loss of consciousness on 4/4/23 Hopi- Patient was apparently asymptomatic till yesterday morning then he had sudden loss of consciousness followed by fall on a cement brick and his clavicle fractured, he had similar complaint in the afternoon. No history of stiffness of both upper and lower limbs up rolling of eye balls , tounge bite . No history of fever, vomiting, neck stiffness, neck pain , and headache .  No history of visual disturbances.  No history of head trauma .  No history of sob , chest pain , palpitations, orthopnea .  Past history  K/c/o DM since 4years and was on medication  K/c/o HTN since 3 years Not a k/c/o asthma , tb , epilepsy and thyroid disorders  Personal h/o  Appetite- normal Diet - mixed Bowel and bladder - regular Any known Allergies- absent Addictions- alcohol- regular 180 ml /day , last intake yesterday morning.  Family h/o - not significant On general examination -  patient is conscious,
Read more

53 year old male presented to the opd with C/O swelling of back of neck 7 years and right thigh since 5 years.

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 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-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan  53 year old male presented to the opd with C/O swelling of back of neck 7 years and  right thigh since 5 years. HOPI : Patient was apparently asymptomatic 7  yrs back then he developed sw
Read more

1801006020 - Long case

Image
24 yrs old male came to the medicine OPD with cheif complaint of unstable gait and tremors since 10 days   HISTORY OF PRESENT ILLNESSES  Patient was apparently asymptomatic 12 years ago he started drinking alcohol after  his mother passed away in a tragic accident , to alleviate that stress.  He started taking alcohol in the form of ARRACK drinking every alternative day about 1-2 glasses a day Over the next few months his consumption gradually increased to 3 glasses a  day further to 6 glasses a day.This continued upto 5 years after he started drinking .  Around 5 years later he shifted to WHISKY  due to ARRACK being banned by the government.He drink around 2 units of whisky daily before going to work and upon returning in the evening he used to feel tired thus used to drink again. In a few months time his drinking increased upto 12 units a day . patient also started chewing tobacco since the last 9 years , around 1 packet every 2-3 days He also complains of sleep disturbances,decrease
Read more