Elog 7 - A 32 yr old man with CKD on MHD with hypertensive retinopathy
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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 diagnosis and treatment plan.
A 32 year old male patient had come with complaints of pedal edema , shortness of breath and low urine output
C/C :
- pedal edema
-shortness of breath
-reduced urine output since 10 days
History of present illness :
The patient was asymptomatic one year ago and developed diminision of vision consulted doctor and was diagnosed with hypertension for which he has been using Tab.Arkamin and Tab.Telma H since 1 year.He was referred to another hospital where he had gotten a creatinine test done and the level was 8.6 and he was started on Arkamin.
He was referred to KIMS for dialysis and had been getting dialysis done since the past 8 months
He developed pitting type of edema below the knee since one month, weakness and backache since one month which relieved on rest.
He has decreased urine output and consumes alcohol [180ml] rarely.
On 18th September 2021 ,
The patient was refferd to orthopaedic department as patient complained of neck pain
- Tenderness noted at L4, L5 region
-no neurological deficits noticed
-no local raise of temperature
History of past illness :
Known case of HTN since 1 year (on Tab.Arkamin , Tab Terma H)
Not a known case of DM,CAD,Asthma,TB,Epilepsy
PERSONAL HISTORY :
Occupation. : Auto driver
Diet – Mixed
Appetite – Normal
Bowels – Regular
Micturition – decreased urine output
Has no known allergies
Drinks alcohol rarely[180ml]
Family h/o :
His brother is a k/c/o HTN
GENERAL EXAMINATION :
Patient was conscious,coherent,cooperative and examined in a well lit room.
VITALS
Pulse rate : 99 bpm
Respiratory rate : 19/min
BP : 150/80mmHg
Temperature : Afebrile
GRBS : 127mg%
SpO2: 98% at room air
PHYSICAL EXAMINATION
Pallor – absent
Icterus – absent
Cyanosis – absent
Clubbing of fingers/toes – absent
Lymphadenopathy – absent
Edema of feet – present,below the knee, pitting type
Malnutrition – absent
Systemic examination:
CARDIOVASCULAR SYSTEM
S1 and S2 heard
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM
Vesicular breath sounds heard
Trachea is in central position
No wheezing
No Dyspnoea
On 8th october JVP was seen prominently and Rhonchi was heard , the patient was put on nebulization with budecort .
ABDOMEN :
Obese shaped abdomen
No tenderness
No palpable mass
No hernial orifices
No free fluid
Liver and spleen not palpable
Bowels sounds are heard
CNS :
Conscious and normal speech
Normal gait
Cranial nerves normal
Sensory system normal
Motor system normal
REFLEXES
RIGHT LEFT
Biceps +2 +2
Triceps +2 +2
Supinator +2 +2
Knee +2 +2
Ankle +2 +2
INVESTIGATIONS ORDERED :
On 2 sept
USG
USG
On 4/9/21 :
Grade II FATTY LIVER
B/L GRADE II RPD
On 5/9/21 :
MRI report :
On 29/9/21 : .
On 5 th October :
The reports were :
Repeat Doppler on 6/10/21
Video of 2 d echo
https://youtu.be/V_XeUBt2nXY
Ecg :
On 5/10/21
Fever chart :
Video of me performing pleural tap ( right lung ) under the guidance of Dr. Vinay ( PG Y1)
Approx 500 ml of pleural fluid was taken on 6/10/21
PROVISIONAL DIAGNOSIS
CKD on MHD secondary to Hypertensive nephropathy
Diagnosis :
UTI , HFpEF ( EF 55%) ,DCMP + with Transudative pleural effusion
L3,L4 spondylodiscitis
With CKD on MHD
With hypertensive retinopathy
K/c/o HTN since 1 1/2 year
PLAN OF MANAGEMENT:
Renal Transplantion
TREATMENT :
On 5/10/21 :
Fluid restriction <1L/day
Salt restriction <2.4L/day
T.Lasix 40mg PO/BD
T.Nicardia 20mg PO/TID
T.Arkamine 0.1 mg PO/BD
T.Shelcal CT po/od
T.Nodosis 500 mg
T.Met XL 50 mg po/od
INJ erythropoietin 4000 units weekly once
BP monitering
On 6/10/21 :
Fluid restriction <1L/day
Salt restriction <2.4L/day
T.Lasix 40mg PO/BD
T.Nicardia 20mg PO/TID
T.Arkamine 0.1 mg PO/BD
T.Shelcal CT po/od
T.Nodosis 500 mg
T.Met XL 50 mg po/od
INJ erythropoietin 4000 units weekly once
BP monitering
On 7/10/21
Fluid restriction <1L/day
Salt restriction <2.4L/day
T.Lasix 40mg PO/BD
T.Nicardia 20mg PO/TID
T.Arkamine 0.1 mg PO/BD
T.Shelcal CT po/od
T.Nodosis 500 mg
T.Met XL 50 mg po/od
T.Metolazol 5 mg po/ bd
INJ iron sucrose 100 mg iv / bd
INJ erythropoietin 4000 units weekly once
On 14/7/21
Fluid restriction < 1. 5 L / day
Salt restriction < 2g / day
INJ piptaz 2.25 mg IV /TID
INJ pan 40 MG iv /od
INJ lasic 40 MG iv /tid
Tab nicardia 20 mg po/od
Tab met xl 50 mg /po/od
Tab hydralazine 12.5 mg po /qid
INJ erythropoietin 4000 iu / sc weekly
T nodosil 500 mg /po/bd
T orofer XT po/bd
INJ iron sucrose 100 mg in 100 ml NS / weekly
Tab ZOFER 4 MG po/tid
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