60 y old male patient with shortness of breath and decreased urine output

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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.

A 60 year old male who is a resident of suryapet ,farmer by occupation came to opd with 

Chief Complaints of :-

- Pedal edema since 3 months

- Shortness of breath Since 20 days

- Decreased urine output since 15 days

- Weakness of lower limbs since 4 days

History of presenting illness :-

The patient was apparently asymptomatic 3 months back when he noticed bilateral pedal edema initially extending upto the ankle and gradually progressed upto thighs which worsened during last 15 days.

- Decreased urine output since 15 days, not associated with frequency, urgency or burning micturation.

- Grade 3 shortness of breath, no aggravating and relieving factors.

- Fever since 15 days intermittent associated with chills and 

rigors.

Series of events :-

History of trauma by fall from tree 25 years back for which he used NSAIDS for 4/5 yrs.

7 years back when patient was undergoing hydrocele surgery he was diagnosed with ckd accidentally for which he got treated by dailysis initially and then he started using medications and was apparently well till 3 months back.

3 months back patient developed bilateral pedal edema, facial puffiness for the first time and shortness of breath so he visited local hospital and they referred to our hospital for dailysis.

Since then patient was coming here regularly twice a weak for dialysis .

After his last dialysis session he went back home and he developed discomfort in chest and weakness of limbs . Patient also had few episodes of altered sensorium in between which was associated with fever and chills .So he was brought to hospital again.

Past history :

He is known case of hypertension since 6 months and is on medication.

Not a known case of asthma,diabetesmellitus,epilepsy,tuberculosis.

Personal history:-

Mixed diet,normal bowel movements,decreased urine output since 15 days .

Addictions :- consumed alcohol for 20 years every 3/4 days

Consumed toddy everyday for 40 years.

Daily routine:-

Before 3 years :-

Wakes up at 5 am and goes to field and toddy trees 

Breakfast at 9 am -rice

Afternoon- lunch 12 pm

Evening drinks toddy 

And dinner by 9 pm and sleep

Now :

Wake up at 8 am 

Breakfast at 9 am

Skips lunch and dinner at 8 pm

He is not going to work,not as active as in the past.

Family history:-

Father had hypertension 

General Examination:

- Patient is conscious, coherent,cooperative.

-Moderately built and nourished.

-pallor present 

Pedal edema - 

- clubbing is seen

- no signs of icterus , generalized lymphadenopathy.

-bilateral pedal edema.( Pitting)

Vitals:-

Temp:99.1°F

PR: 98

Rr: 29/ min

Bp:100/80 mm Hg. 

Spo2: 84%

GRBS:124 mg/dl

-Systemic examination:-

Cardiovascular System:-

On Inspection:-

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

No spine deformity

No precordial prominence

No scars and distended veins 

No Apical Impusle

On Palpation:-

No local rise of temperature and tenderness 

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

No cardiovascular pulsation like no thrills and rubs felt

On Auscaltation-

Mitral area apex -S1 S2heard;no murmur 

Tricuspid area - S1 S2 heard;no murmur 

Aortic area - S1 S2 heard;no murmur

Pulmonary area- S1 S2 heard;no murmur

Respiratory system:

-Position of trachea central.

- Bilateral airway entry present.

-Dyspnea present 

- no wheeze.

Abdomen:

-Scapoid

-No tenderness

-No palpable mass

-Spleen : not palpable

-liver : not palpable.

CNS examination:

Higher mental functions are intact

Cranial nerves are intact

Motor system:

Nutrition:

                         Right Left

Mid arm 25cm. 25 cm

Fore arm. 18 cm. 18 cm

Mid thigh. 37 cm. 37 cm

Mid leg 27 cm. 27 cm

Tone                

                        R. L

Upper limb Hypertonia Hypertonia

Lower limb. Hypertonia Hypertonia 

Power R. L

Upperlimb 4/5 4/5

Lowerlimb 3/5 3/5

Reflexes :  

Superficial :-

Corneal present 

Conjunctival present

Abdominal present

Plantar present 

Deep:-

Reflexes are absent 

Sensory system:-

TEST RIGHT LEFT

I – SPINOTHALAMIC

1. Crude touch. N. N

2. Pain. N. N

3. Temperature. N. N

II – POSTERIOR COLUMN

1. Fine touch. N. N

2. Vibration. Unable to perform

3. Position sense. 3/10. 4/10

III – CORTICAL

1. Two point discrimination. N. N

2. Tactile localisation. N. N

3.Stereognosis. N. N

Cerebellar signs :-

No nystagmus ,no pendular knee jerk,no tremors

Coordination:-

Finger nose test : abnormal 

Heel knee test : abnormal 

Gait:- patient is walking with support by attenders and by bending forward

Investigations:        

                                         

                          

  

                          

  

   

Provisional diagnosis : 

Chronic kidney disease on maintenance hemodialysis with anemia of chronic disease with hypertension.

Treatment 

Inj PIPTAZ : 2.25 gm I.v twice a day. 

Inj LASIX : 40 mg Iv twice a day 

Inj NEOMAL : 14mg IV sos 

 Tab : Oral NODOSIS 500 mg twice a day 

Tab: Oral SHELCAL 50 mg twice a day 

Tab : oral ECOSPRIN 50mg H/S

Tab OROFER once a day 

Tab : DOLO 650 mg QID.

On 28 /11/23 

Patient was on salt restriction < 1.5 g / day 

Patient was on fluid restriction <1.5l per day 

Inj : PIPTAZ 2.25 gm iv /tid 

Inj LASIX 40 mg iv /bid 

Inj MEOMOL 14 mg iv sos if temp >101 

Tab : ECOSPRIN 50mg H/S 

Tab : OROFER once a day 

Tab DOLO 650 mg every 6 hourly 

Tab NODOSIS 500 mg PO /BD 

Tab SHELCALT 500 mg /BD.

On 29/11/23

TAB. LINOD 10mg twice a day. 

Inj LASIX : 40 mg Iv twice a day 

Tab : Oral NODOSIS 500 mg twice a day 

Tab: Oral SHELCAL 500 mg twice a day

Inj.EPO 4000 IU ,SC once weekly

Tab : oral ECOSPRIN 75mg H/S

Inj NEOMAL : 14mg IV sos 

Tab : DOLO 650 mg QID

Inj PIPTAZ : 2.25 gm I.v thirice a day.

 

On 30 /11/23 

Treatment 

Inj PIPTAZ : 2.25 gm I.v twice a day. 

Inj LASIX : 40 mg Iv twice a day 

Inj NEOMAL : 14mg IV sos 

 Tab : Oral NODOSIS 500 mg twice a day 

Tab: Oral SHELCAL 50 mg twice a day 

Tab : oral ECOSPRIN 50mg H/S

Tab OROFER once a day 

Tab : DOLO 650 mg QID

Intermittent CPAP 

Oxygen supplementation 1-2