1801006128 -LONG CASE

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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

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A 55 year old male who was a daily labourer , was brought to medicine opd with 

chief complaints:

•Shortness of breath since 7 days 

•Decreased urinary output since 7 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back then he developed bilateral pedal edema which was on and off in nature(since 1 year) and was present up to ankle and was pitting type.

For this he visited a hospital and he was on conservative management. He was diagnosed with hypertension and started medication .

On the sunday (12/3/23)night around 12am he had an episode of shortness of breath of class 4(NYHA)which was sudden in onset and gradually progressive, associated with Paroxysmal nocturnal Dyspnea and orthopnea.

No history of chest pain , sweating, palpitations.

No history of cough, hemoptysis

Urine output is decreased,

narrow streamlined urine.

No history of burning

micturition , fever.

During his stay in hospital he has undergone dialysis 4 times.

DAILY ROUTINE :

He wakes up around 5 am in the morning and does his household chores , goes to work for 5 to 6 hrs and returns back home around lunch time 1pm and take rest for the day. He will have his dinner around 7 30 pm and goes to sleep at 9 pm. He now has stopped his daily work since a year.

PAST HISTORY :

Known case of hypertension since 1 yr and on medication

Not a known case of diabetes, asthma , epilepsy, Tuberculosis , CAD.

No Similar complaints in the past.

Treatment history:

Drug history: 

Tab TELMISARTAN 40mg OD since 1 year

NSAIDS : taken since 4 years occasionally but from past 2 years taken almost daily for knee pains.

Past surgical history :

No past surgical history 

FAMILY HISTORY :

No significant family history 

PERSONAL HISTORY :

Appetite - Normal

Diet - Mixed

Sleep - adequate 

Bowel habits - regular 

Bladder habits - decreased 

Addictions - history of smoking (beedi 4 per day since he was 20 years old ), history of alcohol consumption (since 30 yrs and occasionally whisky 90 ml each time since past one year ).

GENERAL EXAMINATION :

(Consent was taken)

Patient is conscious, coherent and cooperative.

Moderately built and moderately nourished.

Pallor - present

Icterus - absent

 Cyanosis - absent 

Clubbing- absent 

Lymphadenopathy- absent 

Edema - bilateral lower limb edema , pitting type , seen in ankle region.

VITALS :

Temperature - Afebrile (98.6F)

Pulse rate - 80 bpm

Blood pressure - 130/80 mm Hg

Respiratory rate - 17 cycles per minute 

SpO2 - 95% 

SYSTEMIC EXAMINATION :

CARDIOVASCULAR SYSTEM:

*INSPECTION :

Shape of chest : normal 

No sinuses, scars and engorged veins.

Mild rise in JVP

No Precordial bulge

No visible pulsations

Apical impulse : not well appreciated on inspection

*PALPATION-

Apex beat: Shift to 6th intercoastal space lateral to midclavicular line

No Parasternal heave and thrills

*PERCUSSION :

Left heart border - not confined with in normal limits

Right heart border normal in location

*AUSCULTATION :

S1 , S2 heard. no murmurs. 

RESPIRATORY SYSTEM:

*INSPECTION :

Trachea - midline

Shape of chest - elliptical and bilaterally symmetrical.

Type of respiration : abdomino thoracic

Bilateral airway entry Present

No chest wall defects

Presence of a healing, crusted ulcer on the right hemithorax medial to nipple.

Movement of chest is symmetrical on both sides

No sinuses / scars

*PALPATION :

All the inspectory findings are confirmed

Trachea - central

Chest expansion - symmetrical 

Chest circumference - 34 cms

No Tenderness over the chest

*Percussion:

Tactile voacl fremitus:

                                  Right  Left

Supraclavicular        R      R

Infraclavicular         R       R

Mammary                 R        R

Inframammary       R         R

Axillary                     R        R

Infra axillary           R        R

Supra scapular        R        R

Infra scapular          R       R

Inter scapular          R        R

AUSCULTATION :

Vocal resonance 

                                  Left         Right

Supraclavicular     R            R

Infraclavicular      R            R

Mammary              R            R

Inframammary     R            R

Axillary                   R           R

Infra axillary           R           R

Suprascapular        R          R

Infrascapular         R           R

Interscapular          R          R

Breath sounds wheeze heard 

CNS EXAMINATION: 

1. Higher mental functions:

a. Conscious

b. Well Orientation to time, place and person

c. Speech and language – normal

d. Memory – immediate-retention and recall, recent and remote  are present.

Motor system: bulk and tone are normal

Power is 5/5 in all 4 limbs

Deep tendon reflexes are present and normal

Superficial reflexes are present and normal

No involuntary movements          

Cerebellar signs absent                 

Signs of meningeal irritation - absent                                                                                                           

Per abdomen examination:                                               

*INSPECTION -

shape of abdomen is normal 

No scars and sinuses 

Umbilicus is central 

*PALPATION -

No Tenderness on superficial palpation.

Temperature - Afebrile

Liver is Non Tender and not palpable 

Spleen is Not palpable

*PERCUSSION - tympanic note heard 

*ASCULTATION- Bowel Sounds Heard  

PROVISIONAL DIAGNOSIS :

 Heart failure associated with hypertension.

INVESTIGATIONS:

*Hemogram: 

Hemoglobin - 7.7 gm/dl

Total count - 14,100 cells/cumm

Lymphocytes - 16%

PCV - 23.1 vol%

*SMEAR :

RBC - Normocytic normochromic

WBC - increased count (neutrophilic leucocytosis)

Platelets - adequate

*Kidney function test: 

Serum creatinine - 4.0 mg/dl

Blood urea - 95mg/dl

*ABG :

PH 7.43

Pco2 - 31.6 mmHg                          

Po2 - 64.0 mmHg

HCO3 - 21.1 mmol/l

*Urine examination :

albumin ++

sugar nil

pus cells 2-3

epithelial cells 2-3

Red blood cells 4-5

Random blood sugar - 124 mg/dl

*CHEST X RAY : 

 

*Electrocardiogram :  

 

2d echo:

Final diagnosis:

Heart failure  with AKI on CKD 2° to NSAID abuse with hypertension. 

TREATMENT :

Ryle’s feed : 100 ml milk with 2    scoops protein powder 4th hourly and 100 ml water 6th hourly.

Inj. Thiamine 100mg in 50 ml NS TID

Inj. Piptaz 2.25g IV TID

Inj. LASIX 40mg IV BD

Inj. Erythropoietin 4000IU SC Once weekly

Inj. PAN 40 mg IV OD

Tab. Nicardia Retard 10mg RT BD

Tab. Metoprolol 12.5mg RT OD

Cap. BIO D3 RT OD.

Hemodialysis

Nebulisation with Duolin 8th hourly and Budecort 12th hourly 

Intermittent CPAP

Allow sips of oral fluid 

Monitor vitals.