Gm final practical short case
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Chief complaint
32 year old male patient who is a worker in an electrical industry in Mumbai came to the OPD with right hip pain since 10/10/21
History of present illness:
Patient was apparently asymptomatic 3years ago, then he developed pain in loin region for which he went to a private hospital in mumbai and was diagnosed with bilateral renal calculi and bilateral stents were placed Patient had no problem after that and continued to work.
After 4-5months the stents were removed, just 1 week after stents were removed patient again had pain in his loin. He was taken to the same hospital and bilateral stents were again placed. Patient had no problem after that and continued to work.
About 1 year ago he developed multiple scaly, hyperpigmented plaques noted over trunk both groins and inner thighs, generalised necrosis (+).
Last year he returned to his home town, near nalgonda and started farming, few days later he stopped using his medication.
November,2021 he underwent 20 sessions of dialysis.
Since 1 month he is complaining of severe pain in his right hip and was unable to even get up from chair.
No c/o sob, facial puffiness, chest pain, palpitations, giddiness, decreased urine output, burning micturition.
PAST HISTORY-
Known case of Diabetes mellitus, was on Tab.Glimy M2 OD, but stopped using it after stents were placed.
Known case of Hypertension and was on LASIX 40 mg PO BD
NODOSIS 500 mg PO BD
Personal history:
Sleep- Adequate
Appetite- normal
Diet- mixed
Bowel movement- Regular
Addictions- nil
General examination:
Pt is C/c/c
Pallor present
No Icterus ,Cyanosis, No Clubbing,Lymphadenopathy
Edema of feet +
Vitals:
Temperature : afebrile
Pulse rate: 88bpm
Bp:120/90 mm Hg
Spo2:97% at RA
Grbs - 166 mg/dl
Systemic examination:
CVS - S1,S2 +
RS - BAE +
CNS - NAD
P/A- Soft, non tender
Investigations:
Serology - Negative
Provisional Diagnosis :
B/L Multiple renal calculi largest measuring 13mm in right and 10 mm in left with Obstructive uropathy with Tenia corporis et crusis with h/o Hypertension and Diabetes mellitus with right hip pain under evaluation
Dialysis is done.
Packed red blood cell transfusion.
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