1801006066 - LONG CASE

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

 A 48 year Male patient came to the medicine OPD with chief complaints of 

• Difficulty in breathing since 6 days
• decreased urinary output since 6 days
• Swelling of lower limbs on and off since 1 year

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 year back, then he developed bilateral pedal edema which is on and off in nature and pitting type since 1 year from knee to ankle region, and was on conservative treatment. 

He went to local hospital and was diagnosed with hypertension and started using medication (drug-Telmisartan dosage-40mg)since 1 year.

6 days ago at night, the patient developed sob (grade 3) which is sudden in onset and gradually progressive, associated with orthopnea and pnd.

urine output is decreased - narrow streamlined urine.

no h/o cough

not associated with chest pain 

not associated with sweating 

no history of burning micturition

The patient has undergone dialysis 3 times since his admission.

DAILY ROUTINE 

patient wakes up at 5:30am in the morning and does his household chores and goes to work daily work for 5 hours and comes back between 12-1 pm to have lunch, and takes rest for the day. Patient have dinner at around 7:30pm in evening and goes to sleep at 9pm.

PAST HISTORY

Known case of hypertension 

No similar complaints in the past

Not a known case of DM, asthma, epilepsy, thyroid disorders.

DRUG HISTORY 

Started using Telmisartan 40 mg since 1yr

FAMILY HISTORY 

No similar complaints in the past

PERSONAL HISTORY

Appetite - Normal

Diet - mixed 

Sleep - Adequate

Bowel and bladder - Regular but Decreased micturition

Addictions Smoking history -beedi consumer (4 beedis per day so 6 pack years)

Alcohol history -since 25 years 4 times monthly(whisky 90 ml each time)

GENERAL EXAMINATION

Patient is consious, coherent, and cooperative moderately built and moderately nourished. 

Pallor - present

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - absent

VITALS: 

Temperature - Afebrile

Pulse - 76 bpm

Blood pressure- 130/80 mmhg

Respiratory rate- 17 cycles per min

Spo2 - 95%

SYSTEMIC EXAMINATION

CVS: 

Inspection:

No visible pulsations

Jvp is not raised

No precordial bulge

No chest wall defects.

Palpation:

Apex beat is at 6th intercoastal space in anterior axillary line.

No parasternal heave

No palpable P2

Auscultations:

S1 S2 heard

RESPIRATORY SYSTEM:

Inspection:

No scars, pulsation, engorged veins.

Ulcer present medial to right nipple

shape of chest - elliptical

chest is bilaterally symmetrical

bilateral airway entry present

trachea - Midline 

Palpation:

Trachea is midline

Symmetrical chest expansion

Chest circumference is 34 inches

No tenderness.

Percussion- 

                                      right           left 

supra clavicular          resonant  resonant 

infra clavicular           resonant   resonant 

supra mammary        resonant   resonant 

infra mammary          resonant   resonant

axillary                       resonant     resonant

supra axillary              resonant  resonant

infra axillary               resonant    resonant

supra scapular             resonant  resonant 

infra scapular              resonant   resonant

Auscultation- wheezing heard diffusely around chest

ABDOMINAL EXAMINATION:

shape- scaphoid

tenderness no

no palpable mass

liver not palpable

spleen not palpable

CNS EXAMINATION

speech normal

no focal neurological deficits seen

FINDINGS:

INVESTIGATIONS:

COMPLETE BLOOD PICTURE:

hemoglobin - 8.1gm/dl

total count - 12,680 cells/cumm

neutrophils - 74%

lymphocytes - 12%

pcv - 25.0%

blood group A+

interpretation- Normocytic normochromic anemia with neutrophilic leukocytosis

Platelet count - 2.16 lakhs/cu.mm

COMPLETE URINE EXAMINATION:

albumin ++

sugar nil

pus cells 2-3

epithelial cells 2-3

Red blood cells 4-5

random blood sugar - 124 mg/dl

RENAL FUNCTION TESTS:

urea            123 mg/dl

creatinine 5.7 mg/dl

uric acid    7.8 mg/dl

sodium    138 mEq/L

Potassium    3.3 mEq/L

Serum Iron-  74 ug/dl

24H URINE PROTEIN/ CREATININE RATIO:

Urine protein- 185 mg/dl

Urine creatinine - 0.5g/day

Ratio: 0.37

Urine volume- 125ml

LIVER FUNCTION TESTS:

Alkaline phosphate  312 mg/dl

total protein               6.2 gm/dl

albumin                       3.04gm/dl

ABG ANALYSIS:

pH - 7.13

pCO2 - 34.6 mmHg

pO2   - 64 mmHg 

HCO3 -21.1 mmol/L

O2 saturation 92.1%

       

X-ray CHEST:

                                         2D ECHO:

ECG:

Dialysis done 4 times till date

PROVISIONAL DIAGNOSIS:

  

Chronic Kidney Disease secondary to NSAID abuse.

Heart failure secondary to ckd

Hypertension secondary to ckd with egfr 18ml/min (Stage 4 kidney disease)

TREATMENT:

    

• Ryles feed -100ml milk +protein powder 2 scoops

         4 hourly +100ml water

•    Neb. Budecort and duolin 8hrly
•    Inj. piptaz 2.25 gm iv-TID
•    Inj.Lasix  40mg IV/BD
•    Inj.Pan  40mg IV/OD
•    Inj.Hydrocort 100 mg IV/BD
•    Tab.Telma H
•    Dialysis
•    strict I/O charting
•    Monitor vitals