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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.
Name : Kattekola Sathwik
Roll no : 58
2017 batch
Case details
History
A 60 year old male Presented with the following complaints..
About 2 years ago he had a small ulcer on the left leg for which he went to the hospital and took medication
About 2 months ago he developed pedal edema pitting type on both sides and is of grade 2-3. HE also complained of loin pain He was investigated and diagnosed as Chronic kidney disease and was Given medication in a hospital.
About 15 days ago, he developed SOB which was gradually progressing to grade 3. Orthopnea was present.
He also discontinued his medication from this day
No history of palpitations, chest pain, paroxysmal nocturnal dyspnea.
Past history
History of seizures in the past
No history of hypertension, thyroid disorders,TB
Personal history
Appetite: decreased
Diet: vegetarian
Bowel and bladder: regular
Sleep : adequate
Allergies: no food and drug allergies
Addictions
✓ Alcohol-90-180mL/day since 40 years
✓ smoking 18-20 beedis daily since 40 years
Family history: insignificant
General physical examination
The patient was conscious coherent cooperative.
Well oriented to time place and person
Moderately built and nourished
Pallor : present
Icterus : absent
Cyanosis : absent
Clubbing :absent
Lymphadenopathy : absent
Pedal edema: Bilateral pitting type upto knee level
Vitals
Temperature: afebrile
Respiratory rate: 26 Cycles/minute
Pulse : 96 beats per minute
Blood pressure :120/80 mmHg measured on right arm in supine position
SpO2: 86% at Room air
99% at 6L of O2
Systemic examination
Respiratory system
✓ chest is elliptical and bilaterally symmetrical
✓ equally moving on both sides with respiration..
✓ position of trachea: midline
✓ Apex beat : 5th intercostal space 1 cm medial to mid-clavicular line
✓ on auscultation, bilateral coarse crepts were heard
Cardiovascular system
✓Chest is elliptical and bilaterally symmetrical
✓No engorged veins, scars
✓Apex beat seen and felt at 6th intercostal space 1 cm Lateral to mid-clavicular
✓No parasternal heave
✓ On percussion, cardiac dullnesa was outside the normal limits
✓Auscultation: S1 S2 heard
✓No added sounds/murmurs
Per abdomen : Soft
CNS : Higher mental functions are intact
Clinical images
Pitting edema
Investigations
Chest X ray
On 18/10/2021
On 22/10/2021
2D echo
ECG
on 18/10/2021
TROPONIN I : Negative
BLOOD GROUP : B negative
USG-ABDOMEN
ON 19/10/2021
On 20/10/2021
PROVISIONAL DIAGNOSIS
Chronic renal failure with HFrEF with Uremic encephalopathy
SOAP NOTES
Date :18/10/2021
Diagnosis: CRF with HFrEF (?DCMP) secondary to CAD
Treatment
Tab LASIX 40mg BD
Tab PANTOP 40mg BD
Fluid restriction less than 1.5L/day
Salt restriction less than 2g/day
Tab shelcal OD
Inj erythropoietin 4000 Weekly once
Tab orofer BD
Tab Ecospirin BD
Tab metxl 25mg OD
Tab hydralazine 25mg OD
Neb duolin 4th hourly
Budecort 6th hourly
Date: 19/10/2021
On examination
Patient in conscious
Pulse: 96bpm
BP :130/80 mmHg
CVS : S1
S2 heard
Respiratory system:
✓ Bilateral air entry present
✓ Wheeze heard in all lung fields
Per abdomen: : Soft
Diagnosis : Chronic kidney Disease with HFrEF with uremic encephalopathy
Treatment
1. Inj.Lasix 3mL/hr infusion
2. Inj. PAN 40mg OD iV
3. Tab .MET-XL 25 mg PO -OD
4. Tab ECOSPIRIN OD
5. Tab. HYDRALAZINE 12.5 mg PO-OD
6. Tab.NODOSIS 500 mg PO-BD
7. Tab.Shellal 500mg PO-OD
8.Nebulization with
DUOLIN -6th hourly
BUDECORT -8 th hourly
Date : 20/10/2021
On examination
Patient is irritable
Afebrile
BP : 130/80 mmHg
Pulse :94 beats /minute
CVS: S1 S2 heard
RS : BILATERAL AIR ENTRY PRESENT
Crepts noted in bilateral infra-axillary area
Per abdomen: soft
Treatment
1. Inj. Lasix 40 mg i.v. BD
2. Inj. PAN 40 mg i.v.OD
3. Tab. ECOSPIRIN AV (75/20)
4.Tab. HYDRALAZINE 12.5 mg PO-OD
5.Tab.NODOSIS 500 mg PO-OD
6. Nebulization with
DUOLIN-6th hourly
Budecort -8th hourly
7. Fluid restriction <1.5 L/ day
8. Salt restriction <2 gm/day
9. Inj. ERYTHROPOIETIN 4000 IU weekly once
10. Strict I/O charting.
Date :21/10/2021
Provisional diagnosis: ? Uremic encephalopathy/ Hypoxic ischaemic Encephalopathy
With HFrEF with EF 30%
With CRF
2 sessions of hemodialysis done
1 OPRBC transferred.
Examination
Patient is conscious. Not oriented to tine place and person
Pulse rate :92 beats/min regular
CVS:s1 s2 heard
RS : BAE + Diffuse wheeze over all areas
PA: soft
Treatment
1. Inj. PAN 40 iv OD
2. Tab. MET-XL 25 mg PO-OD
3. Inj. HYDRALAZINE 12.5mg PO-OD
4. Tab . Shelcal 500 mg PO-OD
5. Tab.Nodosis 500mg PO-BD
6. Nebulization with
DUOLIN-6th hourly
Budecort -8th hourly
7.Tab.OROFER XT PO/BD
8. Inj. ERYTHROPOIETIN 4000 IU weekly once
Date :22/10/2021
Provisional diagnosis: ? Uremic encephalopathy/ Hypoxic ischaemic Encephalopathy
With HFrEF with EF 30%
With CRF
2 sessions of hemodialysis done (19/10/21 and 20/10/21)
1 OPRBC transferred.
Examination
Patient is conscious. Not oriented to tine place and person
Pulse rate :92 beats/min regular
CVS:s1 s2 heard
RS : BAE + Diffuse wheeze over all areas
PA: soft
Treatment
1. Inj. PAN 40 iv OD
2. Tab. MET-XL 25 mg PO-OD
3. Inj. HYDRALAZINE 12.5mg PO-OD
4. Tab . Shelcal 500 mg PO-OD
5. Tab.Nodosis 500mg PO-BD
6. Nebulization with
DUOLIN-6th hourly
Budecort -8th hourly
7.Tab.OROFER XT PO/BD
8. Inj. ERYTHROPOIETIN 4000 IU weekly once
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