Case history prefinal

 A 60 year old man, 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 nothing 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 urination 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 their 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.

PROVISIONAL DIAGNOSIS

Chronic Kidney Disease.

INVESTIGATIONS

FINAL DIAGNOSIS

Chronic Kidney Disease

 

TREATMENT

Tab-Nicardia-20 mg 0D

Tab-Nodosis-500mg-BD

Tab-Orofer-BD

Tab-Ultracet

Inj- Erythropoietin.