1801006009 - Long Case

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

CHIEF COMPLAINTS: 

Patient Came to Casualty with chief Complaints of difficulty in breathing since 10 Days

Complaints of swelling of upper limbs and lower limbs since 6 days

Decreased urine output since 6 days

HOPI:

Patient was apparently asymptomatic 1 year back Then he had difficulty in breathing which is Intermittent type, he went to hospital where he was incidentally diagnosed with Chronic Kidney Disease.

He was using a nebulizer to control his Shortness Of Breath on recommendation of a RMP.

10 days back he had sudden onset of difficulty of Breathing, which had progressed to GRADE III  (unable to walk to bathroom), Orthopnea present, unable to sleep and wakes up gasping for air. ( PND  present).

Edema of both upper and lower limbs

Lower limb Edema which is pitting type upto Thigh 

There is a History of fall from a tree 3 years ago. There was no loss of consciousness on fall. He was admitted to the hospital and developed low backache and neck pain later.

 He had fever, cough, loss of appetite for 2 months, later was diagnosed with Tuberculosis and Diabetes. ATT for 6 months and on Oral Hypoglycemic since then

Seasonal Difficulty in breathing (SOB), On and Off and with diagnosis of Chronic Kidney Disease 1 year ago. Increased Shortness Of Breath and Edema since 10 days.

DAILY ROUTINE : 

He is a Farmer By Occupation

He wakes Up at 7 pm everyday, Does his morning Routine and has Tea.

Has Breakfast at 8am

Eats Idli or rice for breakfast

Goes to Field for work and returns in the afternoon.

Has Lunch at 2pm, 

He eats Rice and Curry/Non veg for lunch( Has Non veg weekly once).

He sleeps for 2 hours in the afternoon and wakes up at 4pm. 

Watches TV and reads Newspaper and goes for a Walk in the evening.

By 8:30 he has his dinner.

He Eats Rice and Curry for Dinner.

Goes to Sleep by 9pm

After his fall from the tree and injury to his lower back he Stopped going to work since last 3 years and started getting intermittent SOB.

He developed decreased appetite and difficulty in sleeping.

PAST HISTORY: 

Known Case of Tuberculosis 

Diagnosed 3 years Back and was given Anti-Tubercular Therapy

Known Case of Diabetes II Since Last 3 Years - On Oral Hypoglycemic Drugs.

Known Case Of Chronic Kidney Disease.

Diagnosed with Hypertension When he came to the Hospital. No prior use of Anti hypertensive Drugs.

No H/o Asthma, Epilepsy.

PERSONAL HISTORY : 

Diet - Mixed

Appetite - Decreased

Sleep - Inadequate (PND)

Bowel - Regular

Bladder - Decreased Urinary Output

Addictions - Alcohol use since 30 years. Stopped Drinking 3 months ago.occasional drinker with no pattern.

No allergies

TREATMENT HISTORY

Metformin - For Diabetes

Use of Anti tubercular Drugs in the past.

GENERAL EXAMINATION

Patient was conscious coherent and cooperative.

Moderately Built and Well Nourished

No signs of pallor, icterus, clubbing, generalized lymphadenopathy.

Pedal Edema - Bilateral, Pitting type

VITALS

Temperature - Afebrile

Pulse Rate - 102 bpm

Respiratory Rate - 15cpm

Blood Pressure - 150/90mmg

Sp02 - 97% at Room air

GRBS - 203 mg/dl

SYSTEMIC EXAMINATION: 

CVS EXAMINATION

INSPECTION

No Palpitations

JVP mild raise

PALPATION

Apex Beat - Diffuse Apex Beat on left lateral position.

No parasternal Heave

No palpable P2

Pulse - Regular 

Auscultation : 

S1 S2 Heard

RESPIRATORY SYSTEM

Bilateral Air entry Present

Trachea - Midline

Chest is bilaterally symmetrical and elliptical 

Percussion                     Right                   Left
Supra clavicular:        resonant         resonant   
Infra clavicular:          resonant         resonant 
Mammary:                  resonant                 dull
Axillary:                      resonant               dull
Infra axillary:             resonant                 dull
Supra scapular:         resonant            resonant
Infra scapular:           resonant                dull
Inter scapular:           resonant                   dull   


Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary:                 NVBS         decreased 
Axillary:                     NVBS         decreased 
Infra axillary:             NVBS        decreased 
Supra scapular:          NVBS                NVBS
Infra scapular:           NVBS        decreased 
Inter scapular:           NVBS        decreased 

Central Nervous System

Higher Motor Functions Normal

PER ABDOMEN

INSPECTION 

Abdomen is Mildly distended

Umbilicus is central in position

A visible scar due to injury due to a fall around the umbilicus.

PALPATION -

No Tenderness on superficial palapation.

Temperature - Afebrile

Liver is Non Tender

Spleen is Not palpable

Percussion -

Fluid thrill and 

Auscultation - Bowel Sounds Heard

INVESTIGATIONS : 

X- RAY 

ECG 

2D ECHOCARDIOGRAPHY

Aortic Valve - Sclerotic

Moderate MR +, Moderate TR+ with PAH : Trivial Eccentric TR+

Global Hypokinetic , No AS/MS

Moderate LV Dysfunction+

Diastolic Dysfunction present

ULTRASOUND

USG CHEST

Free fluid noted in bilateral pleural spaces (left more than right) with underlying collapse 

USG ABDOMEN and PELVIS

Mild to Moderate Ascites

Raised Echogenicity of Bilateral Kidneys

LIVER FUNCTION TEST

Total Bilirubin - 0.9 mg/dl

Direct Bilirubin - 0.1 mg/dl

Indirect Bilirubin - 0.8 mg/dl

Alkaline Phosphatase - 221 u/l

AST - 40 u/l

ALT - 81 u/l

Protein Total - 6.8g/dl

Albumin - 4.2 g/dl

Globulin - 2.6 g/dl

Albumin:Globulin Ratio - 1.6

Renal Function Test

Urea - 64 

Creatinine - 4.3

Na+   - 138

K+      - 3.4

Cl-       - 104

Spot urine Protein - 34

Spot urine creatinine - 14.8

Spot Urine : Creatinine Ratio - 2.29

Fasting Blood Sugar - 93mg/dl

PLBS - 152 mg/dl

HbA1c  - 6.5%

ABG :

pH : 7.3

pCO2 - 28.0

pO2 - 77.4

HCO3-. - 13.5

Sat O2 - 94.7

PROVISIONAL DIAGNOSIS

Heart failure secondary to chronic kidney disease. Cardio renal syndrome 

Known diabetic/Hypertensive

With Old history of Tuberculosis 

TREATMENT

1)Fluid Restriction less than 1.5 Lit/day

2) Salt restriction less than 1.2gm/day

3) INJ. Lasix 40mg IV / BD

4) TAB MET XL 25 mg 

5) TAB. CINOD 5 MG PO/OD(IF SBP MORE THAN 110 MM HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 MG IV/OD

8. INJ. ZOFER 4 MG IV/SOS

9. Strict I/O Charting

10. Vitals Monitoring 

11. TAB. ECOSPRIN AV 75/10 MG PO/HS