Medicine Case Discussion
June,23,2021.
E Log Medicine cases
A CASE OF A 45 YEAR OLD MALE WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (HYPERTENSIVE NEPHROPATHY) WITH URAEMIC ENCEPHALOPATHY.
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K.Tejarshini,
Roll no:61,8th SEM,
23/06/2021.
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 comeup with Diagnosis and Treatment plan.
Following is the view of my case:(under the guidance of Dr.Divya ma'am).
CASE DISCUSSION:
Date of admission:21/06/2021.
A 45 YEAR OLD MALE CAME TO THE HOSPITAL ON 21/06/2021 WITH,
CHEIF COMPLAINTS:
Complaint of Altered Sensorium (Hypo active):It's since Morning,lethargy.
History of fever 10 days back,lasted for 3 days,(Outside Creatinine ?11-14.8)
Followed by Pedal edema with Anasarca with Shortness of breath present even at rest .
(Outside Creatinine reports 11)
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymtomatic 5 Years back,then he Complained of lower back pain and neck pain in 2014 and was found to have creatinine of 3.0 mg/dl for which he was managed symptomatically for 1Year.
Patient didn't come for further follow up after 2015 and attenders said that he was noncompliant in taking medications untill last week when he Came with the complaint of Shortness of breath even at rest(grade 4) and loss of appetite .
Now he complained of Altered Sensorium , Shortness of breath at rest, lethargy, Anasarca.
There is no history of decreased urine output ,No history of fluid loss,drug intake.
GRBS:206mg/dl
PR:79beats/min
BP:120/70mm of Hg
SPO2:97% on RA.
PAST HISTORY:
He is a known case HYPERTENSION:5 YEARS and on T.STAMLOBETA OD.
He is also a known case of CHRONIC KIDNEY DISEASE:5 YEARS and on Conservative Treatment
(Outside Creatinine =? 3.2 mg/dl,5years back).
There is no history of DIABETES MELLITUS,CAD, ASTHMA,TB.
Not a Known case of NSAID Use history.
There is no history of blood transfusions.
No history of previous surgeries.
No Radiation exposure.
PERSONAL HISTORY:
Appetite:Normal
Diet: Mixed
Sleep: Adequate
Bowels:Regular
Micturition:Normal
Addictions:
FAMILY HISTORY:
Insignificant family history
GENERAL EXAMINATION:
Patient is Conscious, Cohererent, Co-operative
He is Drowsy but Arousable(Hypo, delayed response to commands).
Moderately built, nourished.
PALLOR: PRESENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
OEDEMA: ANASARCA (+)
VITALS:
TEMPERATURE: AFEBRILE
PULSE RATE:76BEATS/MIN
BP:120/70MM OF HG Measured on left arm
SPO2:98% at room air
GRBS:203mg%
SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs.
Thrills:No
RESPIRATORY SYSTEM :
Bilateral air entry (BAE) Present,
Dyspnea is present,
Wheeze: Absent
Normal vesicular breath sounds are heard,
No adventitious sounds heard.
ABDOMEN:
Shape: Scaphoid,
Soft and non tender abdomen,
Palpable mass: Absent,
Hernial orifices: Normal,
Free Fluid:YES(GROSS ASCITES),
Bruits:No,
No organomegaly,
Bowel sounds: heard.
CNS:
Level of consciousness:Drowsy but Arousable (Hypoactive, delayed response to commands).
Signs of meningeal irritation:No neck stiffness,no kerning's sign.
Higher mental functions: Intact
Reflexes: Present.
PROVISIONAL DIAGNOSIS:
AKI ON CKD(HYPERTENSIVE NEPHROPATHY) WITH URAEMIC ENCEPHALOPATHY.
PLANNING FOR HEMODIALYSIS
INVESTIGATIONS:
ECG:
CBP:
21/06/2021;10:12AM
COMPLETE URINE EXAMINATION:
21/06/2021;10:12AM
ULTRASOUND REPORT FORM:
21/06/2021
22/06/2021;12:14AM
HBsAg-RAPID:
22/06/2021;12:14AM
ANTI HCV ANTIBODIES: RAPID
22/06/2021;12:14AM
HIV 1/2 RAPID TEST:
22/06/2021;12:14AM
22/06/2021;8:00AM
O/E:
Patient is Conscious, Cohererent, Co-operative
Afebrile
PR:83beats/min
BP:140/110mmofHg
CVS:S1S2(+)
RS:BAE(+),NVBS
P/A: Distended;NT
SPO2:94% on Room Air
Treatment:
IVF-NS(0.0+30ml/hr)
INJ.LASIX(40mg/IV/TID)
INJ.NaHCO3(100meq in 100ml NS/IV/Stat)
T.NODOSIS 550mg/P.O/TID
BP/PR/Strict I/O Charting
I would like to thank Dr.Rakesh Biwas sir for giving me this opportunity and also thank's to Dr.Divya ma'am for guidance.
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