A 29 year old male from Miryalaguda...

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                 I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan....

A 29 year old male from Miryalaguda ,a agricultural woker by occupation came to opd with complaints of Bilateral pain in lower limbs upto knee since 22 days

History of Presenting Illness:-

   Patient was apparently asymptomatic 3 years ago then he developed severe sudden pain in right lower abdomen which is insidious in onset and gradually progressive for that he went to local hospital and was diagnosed to  have renal calculus of 4 - 6 mm and relived on Medications. Then after 6 months he developed pain in lower limbs bilaterally which is stabbing type and aggrevated by heavy work

(Like lifting heavy weights) for which he visited a local doctor and was tested the results shows high uric acid levels for which he used medications and relieved. Then he also had history of lower limb pain which is intermittent  for which he used Tab.Acyclophenac whenever he was having episodes of pain. Since 22 days pain is not  reliving on medication and he got admitted to a local hospital his creatinine levels were 8.2 and then he referred to our hospital for Dialysis.

Past history:-

 3 years ago he had lower abdomen pain and he diagnosed fir having renal stones of 4 mm size and relieved on medication.

History of Rat poisoning 5 years ago.

Not a known case of Diabetes,hypertension,Asthma,TB,CVD, Epilepsy and CVA.

Personal history:-

Diet : mixed

Appetite : normal 

Sleep : inadequate due to  pain since 20days Bowel and bladder movements: regular

No allergies but consume alcohol Occasionally .Chronic smoker since 6 years ago and stopped 8 months back.

Treatment History:-

H/o usage of NSAIDs for pain since 2 yrs 

Family History:-

Not significant 

General examination:-

I have taken consent for examination and examined the patient in a well light room.

Patient is conscious,coherent and cooperative

We'll orientated to time,place and person.

Moderately built , moderately nourished

Pallor + 

No icterus ,cyanosis, clubbing lymadenopathy,edema.

Vitals:-

BP -130/80 mmHg

RR - 14cpm

Temp - 98F 

Pulse rate - 78bpm 

Spo2:98%

Grbs - 134 mg%

SYSTEMIC EXAMINATION:-

Cardiovascular System:-

On Inspection:-

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

No spine deformity

No precordial prominence

No scars and distended veins 

No Apical Impusle

On Palpation:-

No local rise of temperature and tenderness 

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

No cardiovascular pulsation like no thrills and rubs felt

On Auscaltation-

mitral area apex -S1 S2heard;no murmur 

Tricuspid area - S1 S2 heard;no murmur 

Aortic area - S1 S2 heard;no murmur

Pulmonary area- S1 S2 heard;no murmur

Respiratory examination:-

Dyspnoea: No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

Abdomen:-

On inspection:-

Shape - Scaphoid , inverted umbilicus, no engorged veins, no scars

On palpation:-

No tenderness, no palpable mass, No Fluid

Liver not palpable

Spleen not palpable

On auscultation:-

No bruits heard

CNS Examination:-

Conscious coherent cooperative well orientated to time place and person.

Speech Normal

Higher mental functions-intact

No signs of Meningitis 

Cranial nerves-Intact

Motor System and Sensory System Normal. 

Investigations:-

Blood urea: 168mg/dl

Liver Function Test:-

Total bilirubin:0.49mg/dl

Direct bilirubin:0.15mg/dl

SGOT(AST):11IU/L

SGPT(ALT):09IU/L

Alkaline phosphate: 190IU/L

Total proteins:7.4gm/dl

Albumin:4.1gm/dl

A/G ratio:1.24

Serum Electrolyte:-

Sodium:142mEq/L

Potassium:4.4mEq/L

Chloride:106mEq/L

Calcium ionized:1.22mEq/L

Serum creatinine: 7.8mg/dl

Complete Blood Picture (Hemogram):-

Haemoglobin: 8.3gm/dl

Total count:7,600cells/cumm

Neutrophils:67%

Lymphocytes:23%

Eosinophils:03%

Monocytes:07%

Basophils:00%

PCV:25.9vol%

MCV:83.4fl

MCH:25.3pg

MCHC:32.0%

RDW-CV:13.4%

RDW-SD:43.4fl

RBC count: 2.03million/cumm

Platelet count:1.90lakhs/cumm

Peripheral blood Smear:-

RBC: Normocytic normochromic

WBC: With in normal limits

Platelets: Adequate

Hemoparasites: No hemoparasites seen

Impression: Normocytic normochromic anemia RBS:114mg/dl

Provisional Diagnosis:-

CHRONIC KIDNEY DISEASE secondary to NSAID abuse 

TREATMENT:-

 1.Tab . LASIX 10 mg/PO/BD 

 2. Fluid restriction < 1.5 L/day

 3.Inj. ZOFER 4 mg / IV/SOS

 4. Tab. NODOSIS 500 MG /PO/BD

 5.Tab. OROFER XT /PO /OD

 6. Tab. SHELCAL PO/OD

 7.Tab CAP BIO D3 60000 micro once week

 8.Salt restriction < 2g/Day

 9.Vital 4th hourly monitoring

 10.strict I/O charting

ON DAY 3:-

Blood Urea:- 168 mg/dl

Creatinine:- 8.6 mg/dl

1 ST Dialysis

Serum electrolytes:-

Sodium:142mEq/L

Potassium:4.4mEq/L

Chloride:106mEq/L

Calcium ionized:1.22mEq/L

ON DAY - 6:-

2nd Dialysis

Serum Creatinine level : 6.7mg/dl

ON DAY-8:-

On 3rd dialysis : 4.7mg/dl