Ckd with poly cystic kidney disease
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, and investigations, and come up with a diagnosis and treatment plan.
THIS IS A CASE OF 65 YEAR OLD MALE PRESENTED TO CASUALTY WITH
CHIEF COMPLAINTS:- vomitings since 4 days 2-3 episodes per day
Loose stools since 4 days
HOPI:- The patient was apparently asymptomatic 10 years back then he developed pain in both knee joints and started using pain killers since then he was fine till 2020.
Then he started having both lower limb swellings and sob on exertion for which he went to hospital and was diagnosed to have ckd and was managed conservatively.
He was fine till 2020 and met with accident sustained right femur fracture .
Femoral nailing was done.
Then patient was fine till march 2023 then he started having decreased appetite since 15 days.
Past history:-
N/k/c/o DM, HTN, EPILEPSY, ASTHMA
Treatment history:-
Treated TB 10 years back with 6months course of anti- tb regimen.
Interlocking nail right femur under c arm
Family history:-
His father suffered from TB.
No significant family history
Personal history:-
Diet:- mixed
Appetite:- normal
Sleep:- adequate
Bowel and bladder:- regular and normal
Addiction:- alcohol occasionally
GENERAL EXAMINATION:-
Patient was conscious, coherent, cooperative well oriented to time and place.
No PALLOR,ICTERUS,CYANOSIS,CLUBBING,
KOILONYCHIA,LYMPHADENOPATHY,
EDEMA
Vitals:-
Temperature:- afebrile
Pulse rate:- 86 beats /min
Respiratory rate:-16 cycles /min
Bp:- right arm 130/ 90
SYSTEMIC EXAMINATION : -
RESPIRATORY SYSTEM : -
Trachea Central
Bilateral air entry present
NVBS
CVS :-
S1 and s2 sounds heard
No cardiac murmurs
ABDOMINAL EXAMINATION :
shape - scaphoid
Palpable mass - no
Liver - not palpable
Spleen - not palpable
Bowel sounds - normal
CNS:-
No focal neuralogical defecits
INVESTIGATIONS:-
DIAGNOSIS:- CKD WITH polycystic kidney disease.
Treatment:-
Haemodialysis
Tab nodosis 500 po/ bd
Lasix 20 mg po/bd
Tab pan 40mg po/od
Tab shelcal ct po/od
Injection erythropoietin in 4000iu
Fluid restriction< 2l/ day
Salt restriction<2g/ day
Zinofer 40 mg po/od
Injection clyndamycin 600mg iv tid
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