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Date of admission:8/12/2021
A 55 year old male patient came to casualty with chief complaint of
-Blurring of vision since 1 year
-Decreased urine output since 2 months
- shortness of breath since 1 1/2 month
- sudden weight loss
- Generalized weakness since 1month
Daily routine:
The patient used to wokeup around 6/7 am in the morning and used to have breakfast and then used to go to work (construction work).He then returns home in afternoon 1-2 pm and have some rice and go back to work and return home by evening 5pm
He used to consume Alcohol daily before sleeping which was around 300--400 ml and used to binge watch then sleep around 11pm.
-His intake of alcohol has increased gradually to 750ml perday(due to family issues and work tensions) and stopped consuming food in the day hours
--He also smooke 5/6 ciggerates perday and number has been increased up to 10 also (daily 1 pack of cigarettes or A pack of beedi)
History of present illness:
Patient was apparently asymptomatic 10 years back and then he diagnosed with Diabetes mellitus type 2 , and on medication of Glimiperide 2mg tablet
On November 15th: Patient was taken to a local hospital due to unconscious and diagnosed with hypertension and raised body creatinine levels and prescribed to be on medication for 15 days
He hasn't visited hospital for followup after 15 days and stay back at home for 3 days and stopped his medication; meanwhile his creatinine levels has been increased and developed SOB and Facial puffiness and decreased urine output ,PND and sudden unconsciousness for which he has been taken again to hospital and got to know that he needs dialysis.
History of Past illness:
4 years back patient has suffered from severe headache and unconscious and then diagnosed thet he had a clot in brain for which he was cured and at that time he came to know that he has Hypertension.
3 years back he had an injury (wooden stick)to toe of left lower limb which gradually progressed into Cellulitis and undergone "LEFT LOWER LIMB AMPUTATION ".
He is a Known case of Diabetismellitustype 2
Has Hypertension since 4 years
Not a known case of Asthma
Not a known case of TB
Not a known case of Epilepsy.
Personal history:
Appetite: Normal
Diet: mixed
Sleep: Inadequate
Bowel and bladder movements:Normal
Habits: addicted to Alcohol and smoking
Family history:
-Patient's mother= known case of Diabetes mellitus type 2 and Hypertension
-Patient's father= known case of Diabetismellitustype 2 ,hypertension , chronic kidney injury and Died.
-Patient's son=k/c/o Hypertension
- patient's daughter = k/c/p Diabetes mellitus.
Medical history:
Patient has been on medication of
T Atorvasartan 100mg
T Pentoxifyllin 400mg since 1 year.
General examination:
Patient is concious, coherent and cooperative at time of joining moderately nourished and with ectomorphic built
Pallor - present
Clubbing-seen
edema seen
No Cyanosis
No icterus
No lymphadenopathy
Thrombophlebitis on his left palm
Vital signs :
Temperature: 98.4 F
Bo:130/80 mmHg
Pulse rate:90
Respiratory rate:20
GRBS:78mg/dl
Systemic examination:
CNS:
Patient is conscious
Speech is normal
Reflexes are normal
CVS :
Inspection:
- chest wall is bilateraly symmetrical
-No precordial bulge
-No visible engorged veins, scars
- No sinuses
-Carotid artery was prominent
Palpation :. Jvp is not felt
Ascultation:
- S1 S2 heard
Respiratory system:
BAE-positive
position of trachea is central
Vesicular breath sounds heard
Dyspnea= present
Wheezing = present
Inspiration crepts in bilateral ISA ,IAA,IMA
Per abdomen :
Inspection: - shape-generalised distension
- umbilicus -inverted
- No visible pulsations
-no striae/prominent sup veins
-No IVC obstruction
Palpation:Non tender
Purcussion: No shifting dullness ,No Fluid trills seen
Provisional diagnosis= Acute renal failure secondary to Alcoholism ?COPD with Cardiac failure k/c/o DM since 10 years and HTN since 3 years
Investigations:
2D Echo
ECG :
Treatment :
4 sessions of dialysis done on
- 11/12/2021
- 14/12/2021
-16/ 12/2021
-18/12/2021
Fluid resuscitation
Salt restriction
Injection Lasix 40 mg IV bd
Injection HAI SC 8am--1pm--8pm
Neb with duolin 8th hrly
Bude cort 12th hrly
Vital monitoring 6 th hrly
Related information :
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