A 39 year old man with fever since 10 days, cough and throat pain since 10 days.

 A 39 year old man, who worked as a book store owner, presented to the hospital with-


• Fever since 10 days,

• Cough and throat pain since 10 days,


HISTORY OF PRESENT ILLNESS


• Patient was apparently asymptomatic 6 years back.

• Pt usually woke up at 8am, eat breakfast by 9am, they would go to their business and have lunch at 1 pm while they are there. They would return back at around 7pm, have dinner by 9pm and retire for the night. 

• One night, Pt suffered with fever and cold-like symptoms, which also caused his appetite to decrease considerably. 

• They experienced severe backpain.

• They went to washroom and while returning from there, they fainted. 

• They visited a local hospital which diagnosed them with high creatinine levels.

• They were kept on Dialysis since then.

• For 4 years, they had no particular problems until they've eaten fish one day.

• This caused patient to have bloodied feces.

• They have noticed no urine output from this point onwards.

• Pt. also complains of episodes of vomiting. 


PAST HISTORY


• The patient DOES NOT suffer from Diabetes Mellitus.

• The patient suffers from Hypertension since 2 years.

• His Hypertension was always apparently under control with medication.

• The patient doesn't suffer from asthma and epilepsy.

• After pt. noticed bloodied feces, he was given a blood transfusion.

• Pt remembers, after this blood transfusion, his symptoms worsened.

• They were never involved in any kinds of accidents.

• They have never undergone any surgeries.


FAMILY HISTORY


• There is no incidence of similar symptoms in any other member of his family. 

• He seems to be the first person to suffer with DM in his family. 

• All the deaths in the family seem to be of natural causes.

• There are no genetic disorders or congenital deformities in his family to his knowledge.


DRUG HISTORY


• On equiry, 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.



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.

• The patient has very poor appetite.

• They appear to be under nourished.

• No micturition.

• Foul smelling feces.

• They apparently have had the habit of drinking 180ml per week since the age of 20.

• The patient is a smoker who smokes 2/3 cigarettes/ day.


ALLERGY HISTORY


• Patient is not allergic to any known drug or food.

• There is no known allergy to dust or pollen in the patient.


GENERAL EXAMINATION


• The patient is concious, coherent and cooperative.

• On examination, patient's mood appears to be well.

• They are underweight.

• The patient has ascites of abdomen. 

• No characteristic facies noted.

• Patient is unable to walk. Needs to use a stand.

• There is no lymphadenopathy present.

• There is no presence of clubbing.

• The patient has icterus.

• No JVP sign.

• There is oedema in both of their legs - pitting type.

• No decubitus sores are present.

• Patient has no palor and pale tongue; appears to be slightly anemic. 

• Patient appears to be mildly dehydrated.

• Vitals (on examining)

      Temperature- 99.3°F

      Respiratory rate- 24 cpm

      Pulse Rate- 84 bpm.

      S1 and S2 are heard. 

      spO2- 98%

      Blood Pressure is 130/90 mmHg.

      BAE +ve

      S1 S2 heard


INVESTIGATIONS-


COMPLETE BLOOD PICTURE (CBP):


HAEMOGLOBIN-11.1gm/dl (low) 


TOTAL COUNT-8200 cells/cumm


NEUTROPHILS-80%


LYMPHOCYTES-11%


EOSINOPHILS-03%


MONOCYTES-06%


BASOPHILS-0%


PLATELET COUNT-2.41


SMEAR-Normocytic,Normochromic


SERUM CREATININE-5.6mg/dl ( normal 0.7-1.3mg/dl) 


BLOOD UREA-72mg/dl (normal 5-20mg/dl)


LIVER FUNCTION TEST (LFT) 


Total Bilurubin-1.18mg/dl


Direct Bilirubin-0.46mg/dl


SGOT(AST)-16 IU/L


SGPT(ALT)-09 IU/L


ALKALINE PHOSPHATE-393 IU/L


TOTAL PROTEINS-6.8 gm/dl


ALBUMIN-4.0 gm/dl


AVG RATIO-1.45






Per abdomen, umbilical hernia is observed, shifting dullness is observed on percussion. 




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PROVISIONAL DIAGNOSIS

CKD in MHD?







TREATMENT


1) Salt restriction <2.4 GM/day.

2) Fluid restriction < 1 lit / day.

3) Tab. Lasix 40 mg.

4) Tab. SHELCAL 500 mg.

5) Tab. Nicardia 20mg.

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