70 yrs old male patient with c/o B/L great and second toe pain for the past 15 days

70 yrs Old male came with complaints of B/L great toe and second toe pain since 15 days

Patient was apparently asymptomatic 15 days ago. Then he developed pain at B/L Great and second toes which is associated with burning sensation, insidious onset , gradually progressive and not associated with h/o trauma

H/o B/L Varicose vein present for the past 6 months

No c/o fever , pain abdomen, loose stools, vomiting, burning micturition, cough , cold

H/o NSAID abuse present 

No c/o decreased urine output , hesitancy , frequency, urgency 

C/o pedal edema (pitting type) on and off

Previous reports

16/06/2023   USG abdomen - Grade 3 Renal parenchymal disease 

30/06/2023     Serum creatinine 2.9 mg/dl

Past history 

K/c/o asthma for 2 yrs and on MDI SALBUTAMOL / SOS

K/c/o Hypertension for 20 yrs and on TAB . AMLONG-AT PO/OD  

K/c/o CAD for 10 yrs ( on irregular medication of TAB. ECOSPRIN -AV 75/10

Not a k/c/o DM , CVA , thyroid disorders

H/o seizures one time 20 yrs ago

H/o hypoglycemic coma 15 yrs ago and on TAB .CLOPITAB 75 mg

K/c/o CKD for 6 months ( on TAB . NODOSIS for 1month)

Personal history 

Appetite - normal 

Mixed diet

Bowels regular 

Micturition - nocturia (4 times/ night)

Alcoholic - 90 ml whiskey for 50 yrs

Tobacco - 2-3 beedis / day for last 50 yrs

General Examination 

Patient is conscious, coherent and cooperative and oriented to time , place and person

Pt is examined in a well lit room after obtaining consent

Pallor present

Icterus absent

Cyanosis absent 

Clubbing absent

Keilonychia absent

Edema up to ankle

Generalised lymphadenopathy absent















Vitals 

BP 130/80 mm Hg

PR 76bpm

RR 20 cpm

Spo2 96%

GRBS 122 mg/dl 

Systemic examination 

CVS S1,S2 present, no murmers

CNS 

RS -Vesicular breath sounds heard over B/L Lung fields

Per abdomen - Soft and non tender

Investigations


Serology -Negative

Неmogram

Hb: 10.5 g/dl

TLC: 4,900

Eosinophils: 13

PCV: 30-6

MCV : 91.9

MCH: 31.5

MCHC: 34.3

RBC count: 3.33 million/cc

Platelet count:1.58 lakh /cc

RBS: 109 mg/dl

FBS:93 mg/ dl

Blood Urea :54

Serum creatinine: 2.6 mg/ dl

LFT 

TB: 0.62

DB: 0.20

AST: 22

ALT: 15

Alp: 117

TP: 6•0

Albumin: 3.8

Alb/Glo : 1.78

Uric acid: 7.9

Electrolytes

Na+: 143

K+: 4•0

Cl- 103

Ca ionised 1.10


USG Abdomen

Findings : Evidence of multiple anechoic cystic lesions notes in left kidney , largest measuring 1.3 x 1.2 cm on the mid pole

Impression 

  1. B/L grade 2 Renal parenchymal disease
  2. Left Renal cortical cysts
  3. Grade 1 fatty liver


2D Echo

  1. Mild TR with PAH, trivial AR , No MR
  2. No RWMA , No AS/ MS , sclerotic AV
  3. Good LV systolic function
  4. Grade 1 diastolic dysfunction, no PE


ECG- normal sinus rhythm


 

Diagnosis : ? Chronic kidney disease ? Peripheral neuropathy HTN For 20 yrsCAD for 10 yrsAsthma for 2 yrs




Treatment

1) Tab PREGABA 75 mg PO/HS

X-X—8 pm

2) Tab AMLONG-AT PO/OD
8AM-X-X

3)Tab  LASIX 40 mg PO/BD
8AM-X-8PM

4)Tab NODOSIS 500mg PO/BD
8AM -X-8PM

5)Tab  SHELCAL PO/BD
8AM -X-8PM

6)Tab ULTRACET PO/BD
8AM-X-8PM




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