General Medicine short case

Hall ticket number- 1601006169

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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 a diagnosis and treatment plan. 

A 55 years old gentleman hailing from Miryalguda who is a labourer by occupation came to the hospital with the chief complaints of difficulty in breathing since 4 days.

History of present illness:-

He was apparently asymptomatic 4 months ago. Then he developed fever which was:

• Onset: insidious 
• Nature: intermittent
• Non progressive
• Low grade
• Not associated with chills and rigors
• No diurnal variation 
• Relieved on medication briefly 

As the fever was not subsiding he went to Miryalguda hospital where he was diagnosed to have Chronic Kidney Disease. He was prescribed medication for the same.

Then 2 months back, he developed bilateral pitting Edema which was initially limited to ankles i.e. Grade 1 and later progressed to below knees i.e. Grade 2.

He developed Dyspnea on 21st April, 2021 around 2 am in night which was:

• Onset- sudden
• Associated with postural variation i.e. it increased on lying down (orthopnea)
• Grade- 4 (According to NYHA classification)

He developed cough 3 days back which was:

• Onset- sudden
• Nature- dry
• Non blood stained

There is no history of chest pain.

No history of palpitations.

No history of syncopal attacks.

No history of oliguria.

No history of hemoptysis.

He is a known case of hypertension since 5 years and is on medication.

He is a chronic alcoholic and a smoker since 18-20 years.

Timeline of events in the life of my patient is described in the following picture-

General examination: 

• He was conscious, coherent, cooperative, moderately built and moderately nourished.
• He is well oriented to day, time, place, person.
• There is pallor.
• No icterus, cyanosis, clubbing, lymphadenopathy.
• There is Bilateral pitting Edema upto knees.

Vitals:

• He was afebrile.
• Pulse rate: 92 bpm, regular in rhythm, normal in character and volume, no Radio- radial delay and no Radio-femoral delay.
• Blood pressure: 180/100 mm Hg measured in right arm and in supine position.
• Respiratory rate: 18 cpm
• SpO2 at room air: 98%

Systemic examination:

1) Cardiovascular system:

• JVP is elevated.

• Apex beat: well localised at the left 5th intercostal space half inch median to mid clavicular line.

 

2) Respiratory system: Hyperpnea

Investigations done on this patient are:-

1) Renal Function Test:-

2) Hemogram 

3) ECG

4) Chest X Ray

Treatment received by the patient:

1) Injection Lasix- loop diuretic 

2) Tablet Nicardia- Calcium Channel Blocker

3) Injection erythropoietin 

4) Tablet Nodosis - antacid 

5) Tablet Shelcal

6) Tablet Orofex

He is undergoing dialysis.

From the history, examination and investigations I am of the opinion that the patient has Chronic Kidney Disease due to chronic hypertension which is responsible for the-

1) Dyspnea

2) Pedal Edema

3) Anemia