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:

ARTERIAL BLOOD GAS ANALYSIS:

. 

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: