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.
2017 batch
Name :- Kattekola Sathwik
Roll no :- 58
Case details
This is the case report of 54 year old male hailing from Rural nalgonda who has come for routine hemodialysis
History of the Present illness
Patient was apparently asymptomatic 10 yrs ago. Then suddenly on one day he developed fever with chills which was continuous in nature not relieving on medications. It was associated with burning micturition.No history of vomiting pain abdomen, diarrhoea.And after 7 days he developed bilateral pedal edema which progressed entire body within a span of2-3 days. He did not pass stools and urine from then
He was taken to a local hospital where they have evaluated the patient and informed him that He has a kidney problem and started him on medications.
For 6 years he was on his medication.
He says that from then his bowel and bladder habits have never returned to previous state
He denies any history of UTI loin pain and SOB during this period of time
About 4 years ago, he again developed generalized swelling of body Starting from feet to face. He also had a problem of not being able to pass urine and constipation (?) . He was taken to hospital where the patient was evaluated and they were informed that his kidneys were damaged and he requires dialysis as his Serum creatinine was elevated (around 11 asper patient). He was also diagnosed with hypertension for which he takes Nifedipine presently. He also was diagnosed with hypothyroidism for which thyroxine tablets are being used By the patient
He was then referred to our institute where he was on Hemodialysis from 4 years. Initially , AV fistula was made in the right forearm which failed after 2 cycles of dialysis. Now he is being dialysed through Left AV fistula. From then he was on medication.
Yesterday , he has come with complaints Of pedal edema upto ankle and for routine haemodiaysis.
He is being dialysed presently.
Past history
-He is a known hypertensive from 4 years. He is on Nifedipine presently.
- He is a known case of hypothyroidism from 4 years on l- Thyroxine
-No history of DM , Asthma, TB, Epilepsy , CAD
- No history of blood transfusions
Personal history
* Decresed appetite since dialysis was started
*Mixed diet
* He is able to pass stools. He gives a history of taking laxatives for passing stools frequently
* Addictions :- He was a chronic alcoholic till about 3 years ago. He used to consume 90-180mL per day
Family History :- No significant family history
General examination
Patient is conscious coherent cooperative
Well oriented to time place and person
Moderately built and nourished
Pallor :- present
Icterus absent
Cyanosis absent
Clubbing absent
Generalised lymphadenopathy absent
Pedal edema :- pitting type upto ankle
Vitals
Temperature : afebrile
Pulse: 82 beats per minute, regular rythm
Respiratory rate: 24 cycles per minute
Blood pressure:130/90 mmHg
Clinical Images
Systemic examination
Respiratory system
✓The chest is elliptical
✓Moving equally on both sides with respiration
✓Apex beat seen and felt at 5 th intercostal space 1 cm to medial to mid-clavicular line
✓Bilateral air entry present
✓Trachea is central
✓Resonant note on percussion over the chest
✓Normal vesicular breath sounds were Heard.
Cardiovascular system
- The chest is elliptical
-Moving equally on both sides with respiration
-Apex beat seen and felt at 5 th intercostal space 1 cm medial to mid-clavicular line
-Heart borders were percussed
-On auscultation, S1 S2 were heard
Per abdomen:
- On inspection , umbilicus was everted, shape was normal, no dilated veins , scars sinuses, fistulae. Hernial orifices were free
-on palpation :- There was no local rise of temperature , tenderness. Liver and spleen were not palpable
- On Percussion :- Tympanic note was appreciated
- On auscultation :- Bowel sounds heard
Central nervous system
✓Higher mental function normal
✓No signs of meningeal irritation
✓On examination,cranial nerves motor system and sensory system are normal
DIAGNOSIS :-
Chronic Kidney disease on Haemodialysis with Hypertension and Hypothyroidism
Investigations
Complete Urine Examination
2. Tab. LASIX 40mg BD
3. Tab. NODOSIS 500mg BD
4. Tab. Shelcal PO/OD
5. Tab. OroferXT PO/OD
6. Inj. Erythropoietin 4000IU sc/iv
7. Inj. Iron sucrose
8. Citrogen OD
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