1701006187 CASE PRESENTATION
LONG CASE:
A 22 yr old patient who is a housewife and resident of Nalgonda came to OPD with the cheif complaints of:
CHEIF COMPLAINTS:-
1) Generalized edema since 5 days
2) Decreased Urine Output since 5 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 12 years back, then she had polyuria, polydypsia and polyphagia for which she was diagnosed with diabetes at the age of 12years at a local hospital. She is on regular medication i.e isophane insulin.
She was diagnosed with hypertension 1 year ago when she went for routine checkup and she is given medications tablet telma 40mg and tablet nicardia 20mg .
On 25th may 2022 patient came to OPD with the complaints of facial puffiness, decreased urine output,pedal edema and she underwent dialysis on alternate days for 5 times.
She was discharged on 4th june 2022 by giving diuretics, antibiotics, insulin and Telma with advice of salt and water restriction and protein diet.
On 10th june 2022 the patient presented with the complaints of generalised swelling of the body since 5days initially involving face and periorbital region and also legs from ankle to thigh also upperlimb and abdomen are involved .
Swelling was insidious in onset, gradually progressive in nature.There are no aggravating or relieving factors.
She also complains of decreased urine output since 5 days.
Patient also complains of nausea and vomiting which is non projectile and non bilious. She is having 2-3 episodes of vomiting every day.
No history of pigmentation
No history of burning micturition, hematuria,
No history of fever , abdominal pain
No history of bone pain
PAST HISTORY:
History of Diabetes mellitus since 12 years
History of Hypertension since 1 year
No history of Tuberculosis, Asthma , CAD
TREATMENT HISTORY:
History of usage of Insulin since 12 years and anti hypertensive drugs i.e tablet Telma 40 mg and tablet Nicardin 20 mg
FAMILY HISTORY:
No significant family history
PERSONAL HISTORY:
Diet: mixed
Appetite: decreased
Sleep: inadequate
Bowel and bladder: bowel regular but decreased urine output
No addictions
No allergies
GENERAL EXAMINATION:
After taking consent , patient was examined in a well lit room after adequate exposure.
On Examination: Patient is Conscious, Coherent and Cooperative, moderately built and nourished. She is well oriented to time, place and person.
Pallor - present
Clubbing - absent
Icterus - absent
Cyanosis - absent
Edema of feet - present
Lymphadenopathy - absent
VITALS:-
On admission i.e on 10-6-22 :
Temperature: 99°F
BP: 140/90 mm hg
PR: 100 bpm
RR: 20 cpm
SPO2: 96%
GRBS: 220 mg/dl
On 12-6-22 her GRBS was 290 mg/dl
Cardiovascular system:
S1,S2 heard,
No murmurs
Respiratory system:
#Inspection:
shape of the chest -bilateral symmetrical, movements are equal on both the sides, trachea appears to be in central in position .
#Palpation:
Decreased movements of chest in the both lowerlobes (infraaxillary and infra scapular)
vocal fremitus decreased in infra axillary and infrascapular area on both sides
#Percussion:
stony dullness in infraaxillary and infrascapular area on both sides
#Auscultation:
Absent breath sounds on both lower lobes ISA and IAA, vocal resonance over both lower lobes.
Abdomen:
#Inspection :
Abdomen -distended and flanks full,
umbilicus inverted and central in position .
No visible veins no scars and sinuses
#Palpation :
soft and nontender
no organomegaly,
Fluid thrill present
#percussion :
Dull note heard over the abdomen
#Auscultation :
bowel sounds +
no bruits
Central Nervous system:
Intact
Higher mental functions are normal
Motor and sensory system normal
No meningeal signs.
INVESTIGATIONS:
Complete Urine Examination:
Colour- pale yellow
Appearance-clear
Reaction- acidic
Albumin- 3+
Pus cells- 4-5
RBC: absent
Casts: absent
Hemogram:
CBP
Hb: 6.2gm/dl
RBC count:2.28 millions /cumm
TC:8200 cells/cumm
Neutrophils: 58%
lymphocytes:31%
MCV:80.4 fl
MCH:27.2 pg
MCHC: 33.8%
RDW-CV:14.7%
Platelet count:2.35 lakhs/cumm
Smear - normochromic and normocytic
Blood urea:
Serum creatinine:
Serum electrolytes:
Blood grouping and RH type:
Blood group: O+ve
HIV Rapid test:
Non reactive
HbsAg Rapid test:
Negative
Anti HCV Antibodies- Rapid test:
Non reactive
Ultrasound Abdomen:
B/L grade 2 RPD
Gross Ascitis
B/L moderate to gross pleural effusion
Chest X-ray:
PROVISIONAL DIAGNOSIS:
CHRONIC KIDNEY DISEASE WITH DIABETES MELLITUS AND HYPERTENSION
TREATMENT:
Inj. Piptaz 2.25 gm TID
Inj. Pan 40 mg IV BD
Inj. Lasix 60mg IV BD
Inj. Zofer 4 mg IV TID
Inj. Human actrapid insulin.6U/iv/stat
Insulin infusion 6ml/hr
Tab.Nicradia 20 mg PO BD
Tab .Telma 40 mg PO OD
Tab. Nodosis 500 mg PO BD
Tab. Orofer- xt PO OD
Tab. Shelcal 500 mg PO OD
Fluid and salt restriction
GRBS monitoring hourly
Monitor vitals 4 th hourly:
Blood pressure monitoring
Pulse rate monitoring
Temperature monitoring
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SHORT CASE:
A 25 year old female patient who is a housewife and resident of Miryalaguda came to OPD with cheif complaints of
CHEIF COMPLAINTS:
High blood pressure ( came for checkup )
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back then she developed hypertension which was found out on her 1 St pregnancy. She had 2 abortions in the past i.e in 1 year back in 2021 and 5 months back in 2022 .Her obstetric formula is P2A2L0.
In 1st pregnancy i.e 1 year back in 2021 when the patient conceived she visited obstetrician and found out to have hypertension which was 150/100 mm hg.She had history of pedal edema. She was started on anti hypertensive drugs i.e tablet labetalol 100 mg PO BD. At around 8 months, patient had Intrauterine death of fetus and baby was delivered by normal vaginal delivery.
Then she stopped taking anti hypertensive drugs.After a gap of 3 months she conceived again in 2022.
In 2nd pregnancy i.e 5 months back in 2022 she conceived and found out to have hypertension which was 160/100 mm hg. She was started on anti hypertensive drugs i.e tablet labetalol 100mg PO BD. At around 8 months preterm delivery i.e normal vaginal delivery was done, the baby died within 1 day.
Now the patient has no history of palpitations, shortness of breath, pedal edema, decreased urine output, headache, blurring of vision.
PAST HISTORY:
History of hypertension since one year
No history of Diabetes mellitus, Tuberculosis, Asthma, CAD
No history of blood transfusion
No history of previous surgeries
TREATMENT HISTORY:
History of usage of anti hypertensive drugs i.e labetalol.
PERSONAL HISTORY:
Diet : mixed
Appetite: normal
Bowel and bladder : regular
Sleep : adequate
No addictions
No allergies
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
On Examination: Patient is Conscious, Coherent and Cooperative well oriented to time, place and person
Clubbing - absent
Pallor - absent
Icterus - absent
Cyanosis - absent
Edema of feet - absent
Lymphadenopathy - absent
VITALS:-
On admission i.e on 8-6-22 :
Temperature: afebrile
BP: 170/100 mm hg
PR: 90 bpm
RR: 22 cpm
SPO2: 98%
GRBS: 164 mg%
On 11-6-22:
Temperature: afebrile
BP: 160/100mmhg
PR: 98 bpm
RR: 16 cpm
On 12-6-22 :
Temperature: afebrile
BP: 120/80mmhg
PR: 74 bpm
RR: 16 cpm
SYSTEMIC EXAMINATION :
CARDIOVASCULAR SYSTEM :
S1 and S2 heard, no murmurs heard
RESPIRATORY SYSTEM :
BAE present, NVBS heard, position of trachea - central
PER ABDOMEN :
soft, non tender.
No organomegaly
CNS:
Higher mental function intact,NAD.
INVESTIGATIONS:
Blood urea : 19
Serum creatinine: 0.8
CBP:
Hb: 14.1
TLC: 9,900
Neutrophils: 65
Leucocytes: 30
PCV : 40.4
MCV: 85.4
MCHC: 34.9
Platelet count: 3.64
RBC: Normocytic normochromic
Thyroid Profile:
T3- 1.32
T4- 10.75
TSH- 2.32
Lipid Profile:
Total cholesterol-204
Triglycerides-201
HDL- 55
LDL-120
VLDL-40.2
PROVISIONAL DIAGNOSIS:
YOUNG ONSET HYPERTENSION
TREATMENT:
1) Tablet. AMLONG 5 mg PO OD
2) Tablet. Zincovit PO OD
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