Diagnosis
DIMORPHIC ANAEMIA(BICYTOPENIA) WITH CKD(STAGE 4) WITH 4 SESSIONS OF
HEMODIALYSIS DONE(2019)
Case History and Clinical Findings
COMPLAINTS:
80 YEAR MALE WITH C/O TINGLING AND NUMBNESS OF BOTH UL AND LL SINCE 1 WEEK.
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC TILL LAST WEEK,THEN DEVELOPED
HAEMATURIA SINCE LAST FRIDAY, IN EACH EPISODE OF URINE OUTPUT, WHICH LASTED
FOR 4 DAYS.NO AGGREVATING FACTORS, NO RELIEVING FACTORS.
H/O DECREASED URINE OUTPUT SINCE 1 MONTH, BUT INCREASED FREQUENCY.
NO H/O BURNING MICTURITION, HESITANCY OR URGENCY
NO H/O BLEEDING MANIFESTATIONS,PETECHIAE,RASH,NO HEMATURIA,NO BLOOD IN STOOL(MELENA),NO BLLEDING GUMS.
NO H/O FEVER, COUGH, COLD, PAIN ABDOMEN
NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA AND PND
TINGLING AND NUMBNESS OF UL AND LL SINCE 1 WEEK.
NO POLYPHAGIA,POLYDYPSIA,NOCTURIA
POLYURIA PRESENT
UROLOGY REFERRAL TAKEN IN VIEW OF HEMATURIA ?URINARY BLADDER CARCINOMA
DIAGNOSIS:BPH WITH GRADE 2 RPD CHANGES
ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS
T.PANTOP 40MG X 1 WEEK
SYP.ALKASTON B6 15ML PO BD WITH WATER
PAST HISTORY:
N/K/C/O HTN,DM,THYROID DISORDERS,EPILEPSY
K/C/O RENAL CALCULI 2 YEARS BACK
H/O DIALYSIS 3 YEARS BACK(2 SESSIONS)
PERSONAL HISTORY:
DIET-MIXED
APPETITE-NORMAL
BOWEL AND BLADDER-REGULAR
ADDICTIONS-CHRONIC ALCOHOLIC SINCE 50 YEARS.90ML/DAY EVERYDAY TILL 2019.
NOW OCCASIONALLY ONCE A WEEK.
CHRONIC SMOKER SINCE 50 YEARS.5-6 BEEDIS PER DAY.
FAMILY HISTORY:
INSIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE
NO PALLOR ,ICTERUS , CLUBBING,CYANOSIS,LYMPHADENOPATHY ,PEDAL EDEMA
SPO2 99% AT ROOM AIR
TEMPERATURE -98.2F
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD ,NO MURMURS,JVP NOT RAISED
RS: BAE,NO ADDED SOUNDS ,NVBS
P/A: SOFT, NON TENDER,BOWEL SOUNDS CAN BE HEARD
COURSE IN THE HOSPITAL:
PATIENT WAS ADMITTED IN VIEW OF TINGLING AND NUMBNESS OF BOTH UL AND LL SINCE
1 WEEK AND COMPLAINED ABOUT HEMATURIA 1 WEEK BACK AND ON FURTHER
INVESTIGATIONS:
HB:7.4--6.9--7.8
TLC:4500--3900--5200
PLT:60,000--70,000--60,000
CUE:PUS CELLS:6-8
RBC:1-2
EPITHELIAL CELLS:1-2
BACTERIA:PRESENT
PATIENT HAD NO BLEEDING MANIFESTATIONS,PETECHIAE,RASH,NO HEMATURIA,NO
BLOOD IN STOOL(MELENA),NO BLLEDING GUMS.
UROLOGY REFERRAL TAKEN ON 20/05/23 IN VIEW OF HEMATURIA ?URINARY BLADDER
CARCINOMA
DIAGNOSIS:BPH WITH GRADE 2 RPD CHANGES
ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS
T.PANTOP 40MG X 1 WEEK
SYP.ALKASTON B6 15ML PO BD WITH WATER
PATIENT WAS TREATED CONSERVATIVELY AND DISCHARGED IN STABLE CONDITION.
Investigation
HB:7.4--6.9--7.8
TLC:4500--3900--5200
PLT:60,000--70,000--60,000
CUE:
PUS CELLS:6-8
RBC:1-2
EPITHELIAL CELLS:1-2
BACTERIA:PRESENT
RBS:101
LDH:208
RETICULOCYTE COUNT:1.1
SERUM IRON:50
UPCR:SPOT URINE PROTEIN:20.4
SPOT URINE CREATININE:60
RATIO:0.34
24HR URINE PROTEIN:278
24 URINE CREATININE:0.54
RATIO:0.51
2D ECHO:
-MILD AR,TRIVIAL TR/MR
-NO RWMA .NO AS/MS,SCLEROTIC AV
-GOOD LV SYSTOLIC FUNCTION
-DIASTOLIC DYSFUNCTION ,NO PAH/PE
USG ABDOMEN:
B/L GRADE 2 RPD CHANGES
B/L RENAL CORTICAL CYSTS
Treatment Given(Enter only Generic Name)
1.IVF AT 75ML/HR
2.TAB.DOLO 650MG PO SOS
3.INJ.THIAMINE 200MG IV BD IN 100ML NS
4.T.FOLIC ACID 5MG PO OD
5.T.LASIX 20MG PO BD
6.INJ.VITCOFOL 1000MCG IM/OD
7.TAB.NODOSIS 500MG PO OD
8.T.SHELCAL 500MG PO OD
9.T.OROFER XT PO OD
10.T.TAMSULOSIN 0.4 MG
11.T.PANTOP 40MG
12.SYP.ALKASTON B6 15ML PO BD WITH WATER
Advice at Discharge
T.FOLIC ACID 5MG PO OD
T.LASIX 20MG PO BD
INJ.VITCOFOL 1500MCG REGIMEN OD X 1WEEK,
ALTERNATE DAYX 1 WEEK,
WEEKLY ONCEX 1 WEEK,
MONTHLY ONCEX 3MONTHS.
T.SHELCAL 500MG PO OD
T.OROFER XT PO OD
T.TAMSULOSIN 0.4 MGX2 WEEKS
T.PANTOP 40MGX1 WEEK
SYP.ALKASTON B6 15ML PO BD WITH WATER
DISCHARGE SUMMARY
RBC:1-2
EPITHELIAL CELLS:1-2
BACTERIA:PRESENT
RBS:101
LDH:208
RETICULOCYTE COUNT:1.1
SERUM IRON:50
UPCR:SPOT URINE PROTEIN:20.4
SPOT URINE CREATININE:60
RATIO:0.34
24HR URINE PROTEIN:278
24 URINE CREATININE:0.54
RATIO:0.51
2D ECHO:
-MILD AR,TRIVIAL TR/MR
-NO RWMA .NO AS/MS,SCLEROTIC AV
-GOOD LV SYSTOLIC FUNCTION
-DIASTOLIC DYSFUNCTION ,NO PAH/PE
USG ABDOMEN:
B/L GRADE 2 RPD CHANGES
B/L RENAL CORTICAL CYSTS
Treatment Given(Enter only Generic Name)
1.IVF AT 75ML/HR
2.TAB.DOLO 650MG PO SOS
3.INJ.THIAMINE 200MG IV BD IN 100ML NS
4.T.FOLIC ACID 5MG PO OD
5.T.LASIX 20MG PO BD
6.INJ.VITCOFOL 1000MCG IM/OD
7.TAB.NODOSIS 500MG PO OD
8.T.SHELCAL 500MG PO OD
9.T.OROFER XT PO OD
10.T.TAMSULOSIN 0.4 MG
11.T.PANTOP 40MG
12.SYP.ALKASTON B6 15ML PO BD WITH WATER
Advice at Discharge
T.FOLIC ACID 5MG PO OD
T.LASIX 20MG PO BD
INJ.VITCOFOL 1500MCG REGIMEN OD X 1WEEK,
ALTERNATE DAYX 1 WEEK,
WEEKLY ONCEX 1 WEEK,
MONTHLY ONCEX 3MONTHS.
T.SHELCAL 500MG PO OD
T.OROFER XT PO OD
T.TAMSULOSIN 0.4 MGX2 WEEKS
T.PANTOP 40MGX1 WEEK
SYP.ALKASTON B6 15ML PO BD WITH WATER
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