Prefinal Case :- AkI on CKD

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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

An 80yr old male patient hailing from rural nalgonda a known case of CHRONIC KIDNEY DISEASE ON DIALYSIS has presented with complaints of

*cough since 15 days

* fever since 15 days

*shortness of breath since 15 days

*decreased urine out put since 3 days.

History of presenting illness:-

The patient was apparently asymptomatic 10 years ago. Then he developed JOINT PAINS AND SWELLINGS IN HIS METATARSO PHALANGEAL JOINT FOLLOWED BY BOTH KNEES for which he went to a local hospital where they said that the URIC ACID levels were increased and have given medications.He had the episodes of joint pain and swelling in all these years, which increased upon intake of non vegetarian food, toor-dal , and smoking Beedi.

After he was started on medication for the above, he was able to walk for 3 years, following which for next 4 years he used stick to walk. Presently he is able to walk only with the help of a stand.

Around at same time, about 10 years ago he developed giddiness and pedal edema . He was diagnosed as Hypertensive and is on medications and he is regularly taking those medication (stamlo 2.5 mg OD)

About since 4 years ago, he developed bowel and bladder incontinence where he was not able to know that he is about to pass stools /urine which is persistent till now.

He discontinued his homeopathic medication from 3 years

His son mentions that since 3-4 years, the patient doesn't recognise family members sometimes and the next day he behaves normally.

Presently, the patient complaints of cough with expectoration since 20 days. Expectoration is mucoid in nature initially he was able to spit out but now removed by suction. He also had complaints of fever with chills from about 20 days with burning micturition.

He also complained of SHORTNESS OF BREATH which was initially of NYHA grade 2 later progressed to grade 4

Then he was taken to a private hospital where they said that he has a kidney problem for which he should undergo dialysis. He was referred to another hospital where he was on dialysis for 5 days and there was no improvement and attender specified that there was no urine output for 2 days during that hospital course. Now the patient was brought to our hospital for dialysis with the above complaints

Past history

* He is a known case of Hypertension since 10 years

* No history of Diabetes mellitus, prior seizures, coronary artery disease tuberculosis, asthma

Personal history

* He was an alcoholic consuming alcohol about once in 3 days

* He used to smoke 20 chuttas daily

* He stopped alcohol intake and smoking about 15 years ago

*Sleep disturbed due to cough

* Bladder and bowel incontinence since 4 years

* Decreased urine output since 3 days

* Appetite is decreased since 15 days

*Consumes mixed diet

Family history

No history of similar complaints in his family

GENERAL PHYSCAL EXAMINATION

*Patient is drowsy

*Not oriented to time and place

*Oriented to person

Patient was moderately built and nourished

He was not able to open his eyes completely

VITALS

* Pulse : 83 beats per minute, regular rhythm , vessel wall was firm in consistency , normal volume and character

* Blood pressure : 110/80 mmHg

*Respiratory rate : 18 cycles per minute

*Temperature ; Afebrile

*SPO2 :-97% Room air

FEVER CHART

RESPIRATORY SYSTEM:

UPPER RESPIRATORY TRACT: Cannot be examined

LOWER RESPIRATORY TRACT:

INSPECTION:

Chest is symmetrical

Trachea – midline

Apical Impulse : visible

Pectus excavatum : present (??)

no dilated veins, sinuses

no visible pulsations over the chest

Intercostal muscle retractions seen in inspiration.

PALPATION:

Trachea – midline/shifted

sternum was depressed

dilated veins – not present

Apical impulse : felt at 5th intercostal space 1 cm medial to mid clavicular line

Chest movement : asymmentrical (decrease on left side )

Tactile Fremitus : resonant note felt

PERCUSSION: Dull note in left infra mammary , mammary and left infraclavicular areas

* Other areas were resonant

*Posteriorly not percusswd

AUSCULTATION:

1. Breath sounds : Vesicular breath sounds in all lung fields

2. CREPITATIONS were heard in infraaxillary fields

3. supramammary Grunting was present on leftside

4. Vocal fremitus was resonant in all areas

CARDIO VASULAR SYSTEM

* Chest is bilaterally symmetrical

* JVP was not raised

* No precordial bulge

* No parasternal heave

* APICAL IMPULSE WAS SEEN AND FELT OVER 5TH INTERCOASTAL SPACE 1 CM MEDIAL TO MID CLAVICULAR LINE

* On percussion, the heart borders were in normal limits

* On ausultation of the auscultatory areas of heart, S1 S2 Were heard

* No murmurs

CENTRAL NERVOUS SYSTEM

1. HIGHER MENTAL FUNCTIONS:

a. Consciousness : DROWSY

b. Orientation to time, place :- absent

c. Speech and language – slurred speech

d. Memory – intact

2. CRANIAL NERVES :

* 9,10,11, 12: Could not be elicited due to O2 mask

* Other cranial nerves are normal

3. MOTOR SYSTEM

TEST	RIGHT	LEFT
I – BULK a. Inspection b. Palpation	Normal Normal	Normal Normal
II – TONE a. Upper limbs b. Lower limbs	Normal Normal	Normal normal
III – POWER	cannot be examined	cannot be examined
IV DEEP TENDON REFLEXES SEE BELOW.....
V – COORDINATION	CANNOT BE EXAMINED
VI – GAIT	CANNOT BE EXAMINED
VII – INVOLUNTARY MOVEMENTS	ABSENT