General medicine case 10
A 75 year old male patient with severe body ache,joint pains
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Case:
A 75 year old male patient with severe body aches, joint pains since 2 years.
Patient had a chief complaint of swelling over right inguinal region since 1 year.
History of present illness:
Patient was apparently asymptomatic 2 years back before the standing illness.Then the patient had experienced severe body aches and joint pains since 2 years.
Patient had pain over left retroperitoneal area 2 years back where he visited a hospital and was diagnosed with left kidney failure but no medications were taken by the patient in respect to that.
1 year back pt developed swelling in the left inguinal region which was small initially and has grown gradually to the present size.
After 1 year that is 10 days back before getting admitted to our casualty patient had anasarca,facial puffiness,pedal edema, loss of speech for 3 days, there was macroglossia and mild paralysis and when he visited a hospital it was found that both the kidneys were damaged and was suggested to kims.
On admission, after dialysis, patient had night fever for 3 days and burning sensation in knee and feet.
Patient c/o pain on filling of bladder and relief on emptying since then
C/o bilateral pedal edema with morning facial puffiness since 10 days.
Past history
history of DM,HTN
No h/o Epilepsy/TB/Thyroid disorders
Personal history
Diet : mixed
Appetite : normal
Bladder:painful micturition.(micturition:2 to 3 times a day)
Bowel movements:normal
Sleep : disturbances
Family history
No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders
No similar complaints in the family previously.
Treatment history
Not significant.
General examination
Patient is conscious, coherent and cooperative.
Oriented to time,place and person.
No pallor, history of icterus previously but not now,no cyanosis,no clubbing,no lymphadenopathy.
Vitals
Bp :160/100 mm hg
Spo2: 98%
GRBS 113 mg/dl
Temperature: afebrile
Systemic examination:
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge.
Palpation:
JVP: normal
Auscutation:
Normal with regular heartbeat
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Normal Bilateral air entry
No AV sounds
PER ABDOMEN:
Normal. No mass is palpable.
No organomegaly
CENTRAL NERVOUS SYSTEM:
Patient is Conscious, coherent and cooperative.
Provisional diagnosis:
Irreducible indirect incomplete inguinal hernia.
Investigations:
HEMOGRAM:
USG report
ECG -30/10/21
ECG-05/11/21
Final diagnosis:
POLYCYSTIC KIDNEY DISEASE,
LEFT INGUINAL HERNIA.
Treatment:
Tab.lasix 40 mg po/bd
Tab.nicardia 10mg
Tab pan 40 mg po/od
Tab. Orofer XT po/od
Fluid restriction <1.5 lit/day
Salt restriction <2.4g/day
Inj. Piptaz 2.2mg iv/tid
Tab. Dolo 650 mg po/tid
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