general medicine case
60 year old male patient , who works as a daily wage worker hailing from Palem presented to the hospital with-
• reduced micturition and defecation since 2 months.
• burning sensation on micturition since 2 months.
HISTORY OF PRESENT ILLNESS
• Patient was apparently asymptomatic 2 month back.
• The patient is a retired coolie who does work in the day.
• He wakes up at 6am, roams around his village, and he take rest at around 10pm.
• 2 weeks after Dusshera (2 months back), patient suffered with a dizziness and cough which he attributes to "cold".
• Patient was taken to an ENT specialist who ruled him clear of any problem.
• The same day, the patient noticed an acute decrease in his defecation and micturition.
• When patient was taken to the hospital in Nakrekal where he was diagnosed with Renal failure.
• He was put on Maintainance Hemodialysis since then.
• Patient recollects that after 5 days of dialysis, patient's micturition and defecation was somewhat restored.
• Till date, patient has underwent about 15+ dialysis in the span of 2 months.
• Patient was then admitted in Hyderabad as it was easier for his wife to take him to the hospital as she works there.
• However, due to financial crises, later the patient was admitted to this current hospital.
• As of yesterday, patient complains of neck pains, but is feeling better compared to the past week.
PAST HISTORY
• The patient doesn't suffer from Diabetes Mellitus.
• The patient suffer from mild Hypertension.
• The patient doesn't suffer from Tuberculosis.
• The patient also doesn't suffer from asthma nor epilepsy.
• They were never involved in any kinds of accidents.
• They have undergone one corrective surgery for a hydrocele patient developed 20 years back.
FAMILY HISTORY
• There is incidence of patient's elder sister suffering from renal disease, but no treatment was taken for that disease.
• There are no genetic disorders or congenital deformities in his family.
PERSONAL HISTORY
• The patient consumes a mixed diet of vegetarian and non vegetarian food.
• Since his illness, the patient has been only taking vegetarian food.
• Patient's appetite is good.
• Patient is overweight.
• They appear to be adequately nourished.
• Sudden decrease in micturition since the onset of illness
• Bowel movement is constipated.
• They apparently have had the habit of smoking chuttas and drinking 90ml of unspecified alcohol almost daily.
• They have completely ceased from all the above mentioned habits since 2 months.
• The patient doesn't have a habit of chewing pan.
ALLERGY HISTORY
• Patient is not allergic to any known drug or food.
• There is no known allergy to dust or pollen in the patient.
DRUG HISTORY
• On enquiry, the patient refused to have taken any sorts of steroids, oral diabetes drugs, diuretics, ergot derivatives, monoamine oxidase inhibitors, hormone replacement therapy or contraceptive pills — prior to coming to the hospital.
GENERAL EXAMINATION
• The patient is concious, coherent and cooperative.
• On examination, patient's mood appears to be well.
• Their built is endomorphic.
• The patient has no characteristic facies.
• No characteristic gait noted.
• There is no lymphadenopathy present.
• There is no presence of clubbing.
• The patient has icterus.
• JVP sign unable to notice.
• There is no oedema in legs.
• No decubitus sores are present.
• No pruritis is present.
• Patient has pallor.
• No related oral findings found on examination.
• Patient appears to be mildly dehydrated.
• Vitals (on examining)
Temperature- Afebrile.
Respiratory rate- 19 cpm
Pulse Rate- 82 bpm.
S1 and S2 are heard.
spO2- 99%
Blood Pressure is 140/110 mmHg.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
CHRONIC KIDNEY DISEASE
FINAL DIAGNOSIS
Chronic Kidney Disease
TREATMENT
Tab-Nicardia-20 mg 0D
Tab-Nodosis-500mg-BD
Tab-Orofer-BD
Tab-Ultracet
Inj- Erythropoietin.
