General medicine case 11
A 53 year old male patient with Shortness of breath, difficulty in swallowing and headache
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Case:
A 53 year old male patient with Shortness of breath, difficulty in swallowing and headache since 1 month.
History of present illness:
Patient was apparently asymptomatic 3 years back before the standing illness.Then the patient experienced shortness of breath, difficulty in swallowing and headache since 30 days for which he was admitted into the hospital.
It all started 3 years back when the patient noticed shortness of breath and pedal edema where he was admitted to NIMS.
There he was told that he had some blackish discoloration on one of his kidney,apparently they concluded it as one of his kidney's got damaged.
At the same time they noticed that patient was suffering with TUBERCULOSIS.
They stayed in NIMS and took the treatment for a month and then got discharged.
For TB, they had taken tablets for 6 months after which they say that it got subsided.
Before 3 years patient's daily routine:Patient used to wake up around 4 or 5 o'clock and goes to farm for supplying irrigation nd reurns to home by 8 o'clock and takes food and goes back to fields and works until 4 o'clock and comes back to home takes food before 8 o'clock and then goes to sleep
Then 1 month back patient was suffering from shortness of breath, headache,pain in limbs for which he was taken to NIMS and it was told that both of his kidney's got damaged and there was reactivation of tuberculosis.
In NIMS he underwent 4 dialysis and since it is long distance from the patient's place he came to kims and had undergone 5 more dialysis.
Patient also complaints of mild neck stiffness after an accident 1 year back.
Past history
H/o HTN
K/c/o TB 4 years back
No history of DM/Epilepsy/Thyroid disorders
The patient had not undergone any surgeries, blood transfusion.
Personal history
Diet : mixed
Appetite : decreased
Bowel and bladder : decreased sometimes
Sleep :adequate
Addictions: Patient used to smoke 1 to 3 cigars per day and alternative days of alcohol consumption 3 years back.Now,there was occassional consumption of alcohol.
Family history
No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders
No similar complaints in the family previously.
Treatment history
Medications like Rifampicin,ethambutol,isoniazid,pyrazinamide were taken for tuberculosis.
General examination
Patient is conscious, coherent and cooperative.
Pallor is present .
Bilateral pitting pedal edema is seen.
no icterus,no cyanosis,no clubbing,no lymphadenopathy.
Vitals
Afebrile
Bp :140/80 mm hg
PR: 98 bpm
Spo2: 98%
Respiratory rate:24/min
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
No thrills
RESPIRATORY SYSTEM-
Position of trachea: central
Dyspnoea is present
Breath sounds: vesicular
Wheezing: negative
PER ABDOMEN:
Shape : scaphoid
No mass is palpable.
No organomegaly
Bowel sounds: positive
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
Reflexes: present
Provisional diagnosis:
CKD on MHD
k/c/o TB 4 years back.
Investigations
On 8/11/21
BP:130/80 mmhg
PR : 72 bpm
CVS: S1 and S2+
P/A : soft
On 21/11/21
BP: 130/90 mmHg
PR: 98 bpm
CVS S1 S2+
R/s: b/l crepitus + in all areas
P/A : soft
Serum iron:69 ug/dl
Serum creatinine:6.5 mg/dl
Blood urea:197 mg/dl
Random blood sugar:108 mg/dl
USG REPORT:
ECG:(21/11/21)
Clinical images of patient:
Final diagnosis:
Reactivation of tuberculosis
????
Treatment plan:
20/10/21
Tab.lasix 40 mg orally
Tab.pantop 40 mg once daily
Tab.orofer xt once daily
Inj.erythropoietin 400 IU
Tab.amlong twice daily
Tab nodosis 500 mg
Tab.shelcal
2/11/21
Tab.lasix 40 mg orally
Tab.pantop 40 mg once daily
Tab.orofer xt once daily
Inj.erythropoietin 400 IU
Tab nodosis 500 mg
Tab.shelcal
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