A 58yr male patient with complaints of drowsiness, altered sensorium, vomitings from 1 day.
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A 58 yr old Male patient resident of Chotuppal presented to OPD with complaints of altered sensorium and drowsiness from 1day & Vomiting from morning .
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 yrs back then he developed Polyuria,polydypsia,diagnosed as Type 2 Diabetes mellitus & Hypertension.
3 yrs back he had history of Pedal edema , shortness of breath and diagnosed as Renal failure and used no medicines.
1 yr back he had history of Right sided Hemiplegia ,so patient was kept on Antiplatelet and physiotherapy .
20 days back he had history of Pedal edema ,shortness of breath , decreased urine output,dialysis was done .
HISTORY OF PAST ILLNESS:
He is a known case of-
Diabetes mellitus from 5 yrs .
Chronic kidney disease from 3yrs
Cerebrovascular accident 1yr back.
Hypertension from 3yrs
No h/o , asthma,tb , epilepsy.
PERSONAL HISTORY: farmer by occupation
Married
diet : mixed
Appetite: decreased
Bowel : irregular
Urine output: decreased
Sleep: adequate
Addictions: Alcohol occasionally
No h/o of smoking
FAMILY HISTORY:Not significant
GENERAL EXAMINATION:
Patient is conscious, incoherent, cooperative moderately built and nourished.
pallor : mild
No icterus
No clubbing
No koilonychia
No lymphadenopathy
Bp:. 130/80
PR : 90beats/min
Spo2:96%
CNS :On examination upper and lower limbs showed hypertonia ,
Biceps. Triceps. Supinator. Knee. Ankle.
Right : 2+. 2+.
-. -. -
Left :. +. +
-. -. -
Cranial nerve functions can't be elicited as he isnt cooperative.
Speech : incoherent
CVS: S1 S2 +
RS: BAE+
Abdomen:
Soft,non tender, distended.
No sinuses,scars ,fistula
Hernial orifices free
On palpation no Organomegaly
On auscultation Bowel sounds heard
Umblicus : inverted
Investigations: COMPLETE BLOOD PICTURE
RENAL FUNCTION TESTS:
LIVER FUNCTION TEST:
ECG:
PROVISIONAL DIAGNOSIS:
Chronic kidney disease on Hemodialysis , Hypertension, DM - Type 2 , Left CVA .
TREATMENT:
Inj.LASIX 40mgIV/BD
Inj.ZOFER 4mg IV
TAB CINOD 10mg PO/BD
TAB SHELCAL - PO/OD
TAB OROFER -PO/OD
TAB BIO-D3 0.25mg PO/OD
TAB ECOSPIRIN - PO/
GRBS: 6th hourly
Temperature : Charting
Fluid salt restriction
Clinical pictures:
posted by 54 Harika Kathumandi @ December 02, 2021
