1801006161,LONG CASE

1801006161,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.

Case

A 50 year old male patient farmer by occupation came to the OPD with

CHIEF COMPLAINTS  :

 - shortness of breath since 13 days 

  - complaints of edema involving both lower limbs since 9 days 

 -Decreased urine output since 9 days

HISTORY OF PRESENTING ILLNESS:


Patient is apparently asymptomatic 13 days back then he developed 

-Shortness of breath which was insidious in onset and  gradually progressive and know it has been progressed to Grade 4 ,which is aggrevated on lying down and  walking and relieved on sitting position.

- He also had developed bilateral pedal edema ,since 9 which is insidious in onset and pitting  type in nature and which was  initially Grade 1 and know it has been progressed to Grade4

-He also had decreased urine output since 9 days.

No history of chest pain,palpitations,syncope,fever, cough ,hemoptysis,burning micturition and knee pains.


PAST HISTORY:

He has an history of fall from tree 10 years back

He was also diagnosed with Tuberculosis and Diabetis mellitus 3 years back 


He also  noticed swelling in both legs and consulted a doctor and was diagnosed with Chronic kidney disease.

-Not a known case of ; Hypertension, thyroid, Asthma

TREATMENT HISTORY:

Drug history:

 -uesd NSAIDS intermittently to relieve neck pain

 -Antitubercular therapy (for tuberculosis)

- Metformin 500mg three times a day(for Diabetis mellitus)

Past surgical history:

No  history of any surgeries in the past


PERSONAL HISTORY:- 


-Patient takes mixed diet

-Appetite is normal 

-Sleep is adequate 

-Bowel - regular

-Bladder- urinary output was decreased from 9 days

-Addictions : Drinks alcohol occasionally 


-Daily routine:

The patient was a farmer by occupation and wakes up at  6 am and has his breakfast at 7 am goes to work  ,completes work by  afternoon ,takes rest and has dinner at 8 pm ,sleep at 10pm

He is now staying at home since the  fall from tree due to low backache   . He is not going to work anymore      


FAMILY HISTORY:- 

No significant family history 


ALLERGIC HISTORY:- 

No allergies to any kind of drugs or food items


GENERAL EXAMINATION:- 


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

Moderately built and nourished

No pallor 

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

 -Pitting edema seen in both lower limbs

VITALS:

Temperature - Afebrile
Pulse Rate - 102 bpm
Respiratory Rate - 15cpm
Blood Pressure - 150/90mmHg
Sp02 - 97% at Room air
GRBS - 203 mg/dl



SYSTEMIC EXAMINATION: 
CVS EXAMINATION


INSPECTION:
Shape of chest is normal
Jugular venous pressure is mildly raised
No precardial bulge
Apex beat is not well appreciated
No dilated veins


PALPATION
Apex Beat - Shifted to 6th intercostal space lateral to mid clavicular line
No parasternal Heave
No thrills 


PERCUSSION:
Left border of heart- Shifted laterally
Right border of heart is normal in location

AUSCULTATION:
S1 S2 Heard and no murmurs



RESPIRATORY SYSTEM

INSPECTION: 
-Bilateral Air entry Present
-Trachea- central 
- Movements of Chest decreased on left side
- Type of respiration- abdominothoracic


PALPATION:
-All inspectory findings confirmed by Palpation 
- Expansion of chest decreased on left side.
-Tactile vocal fremitus
Right                   Left
Supra clavicular:        normal       normal
Infra clavicular:          normal       normal
Mammary:                  normal        normal   
Inframammary          normal        decreased 
Axillary:                      normal          normal
Infra axillary:             normal       decreased
Supra scapular:         normal        normal
Infra scapular:           normal        decreased  
Inter scapular:           normal         normal



PERCUSSION:
 
                                         RIGHT               LEFT         
Supra clavicular:        resonant    resonant
Infra clavicular:        resonant   resonant 
Mammary:                resonant    resonant 
Inframammary         resonant   resonant 
Axillary:                      resonant      resonant 
Infra axillary:          resonant     dullnote
Supra scapular:       resonant     resonant 
Infra scapular:           resonant       dullnote
Inter scapular:           resonant      resonant 



AUSCULTATION:

- Vocal resonance 

                                     Right.                   Left

Supra clavicular:.       Normal               Normal
Infra clavicular:          Normal           Normal
Mammary:                   Normal             Normal
Inframammary:          Normal           Normal 
Axillary:                        Normal                 Normal
Infra axillary:              Normal             decreased 
Supra scapular:           Normal                 Normal
Infra scapular:            Normal           decreased 
Inter scapular:            Normal              normal


Breath sounds             
                                        Right.                   Left

Supra clavicular:.       Normal               Normal
Infra clavicular:          Normal           Normal
Mammary:                   Normal             Normal
Inframammary:          Normal           Normal 
Axillary:                        Normal                 Normal
Infra axillary:              Normal             decreased 
Supra scapular:           Normal                 Normal
Infra scapular:            Normal           decreased 
Inter scapular:            Normal              normal


 



ABDOMEN EXAMINATION:

INSPECTION 
Abdomen Shape-Normal
Umbilicus is central in position


PALPATION -
No Tenderness on  palpation.
Temperature - Afebrile
Liver is Non Tender 
Spleen is Not palpable


 PERCUSSION: tympanic note 

AUSCULTATION Bowel Sounds Heard



 CENTRAL NERVOUS SYSTEM : 

Patient is conscious coherent and cooperative
Speech is normal 
No signs of meningeal irritation
Cranial nerves - intact 
Sensory system normal 
Motor system:
Tone - normal 
Power - bilaterally 5/5 
Deep tendon reflexes 
Biceps : ++
Triceps : ++
Supinator: ++ 
Knee : ++
Ankle : ++
Superficial reflexes - normal 
Gait - normal  



PROVISIONAL DIAGNOSIS:

Heart failure with left Pleural Effusion 



INVESTIGATIONS:

CHEST XRAY

ECG
X ray skull
ULTRASOUND

USG CHEST

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

USG ABDOMEN 

Raised Echogenicity of both kidneys
  

Hemogram: 

Hemoglobin 11.7 gm/dl

Total count    9,000 cells/cumm

Neutrophils. 74 

Lymphocytes 20

Eosinophils 2

Monocytes 4

Basophils 0

Pcv. 36.5 vol

Mcv. 82.8 fl

RDW- CV 19.1 %

RBC COUNT:. 4.4 million/cu/mm





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
Spo2-94.7


DIAGNOSIS:


HEART FAILURE WITH reduced  EJECTION FRACTION

AND BILATERAL PLEURAL EFFUSION 

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

WITH K/C/O DM II and TUBERCULOSIS SINCE 3 YEARS.



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. Vitals Monitoring 
10  TAB. ECOSPRIN AV 75/10 MG PO/

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