1601006089 LONG CASE

 

1601006089: long case

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. 

A 65 year old male resident of veliminedu, chityala who is maestri  by occupation, was brought to the hospital on 16th of April 2021 with chief complaints of swelling in both the legs since 14 days, decreased urinary output since 10 days and altered sensorium since 2 days 

History of presenting illness :

The patient was apparently asymptomatic 14 days ago, he then developed swelling in both the legs which was insidious in onset, gradually progressive, grade 3 pitting oedema, aggravated on rest and relieved by walking. It was associated with facial puffiness which was noticeable early in the morning. History of decreased urine output since 10 days. Members of the family complained of abnormal behaviour such as inappropriate shouting since 2 days and not allowing to touch him.

Not associated with nausea, vomiting, dyspnea, fatigue, abdominal pain, cough or palpitations. 

Past history: 

Similar complaints of pedal oedema and decreased urinary output were present 5 months ago. The patient took medication (Furosemide 10mg) prescribed by a local doctor and stopped the medication once the symptoms subsided. 

He is a known case of hypertension since 12 years and is taking Metaprolol and Amlodipine since then. 

Not a known case of diabetes mellitus, tuberculosis, asthma and seizures. 

Personal history: 

Diet: Mixed 

Appetite: Decreased

Bowel and bladder: Altered 

Sleep: Adequate 

Addictions: None 

Family history: 

No significant family history. 

Treatment history: 

He has been put on dialysis since admission and has completed 6 sessions. 

Torsemide 10 mg 

General examination: 

Patient is in altered sensorium while examining. 

Temperature: Afebrile 

Pulse rate: 82 bpm, regular in rhythm, normal in volume and character. Their is no radial and radio femoral delay 

Blood pressure: 140/80 mm of Hg 

Respiratory rate: 16 cycles per min 

Pupils: Bilateral reacting to light

Physical examination: 

Pallor: present 

Icterus: absent 

Cyanosis: absent 

Clubbing: absent 

Oedema: absent 

Lymphadenopathy: absent 

Central nervous system examination: 

GCS: E4V3M4

Motor system :

                               Right               Left 

Tone: 

Upper limb -           Normal          Normal 

Lower limb -           Normal          Normal 

Reflexes: 

Biceps -                  2+                   2+ 

Supinator -             2+                    2+ 

Triceps -                 2+                    2+ 

Knee -                     2+                    2+ 

Ankle -                    1+                    1+ 

Babinski -             Negative           Negative 

• All superficial reflexes are intact. 

• Sensory system and cranial nerves: not able to assess. 

Per abdomen examination: 

Umbilicus midline and inverted 

Soft, non tender and no organomegaly 

No shifting dullness or fluid thrill. 

Bowel sounds are present. 

Kidneys were not palpable bimanually. 

CVS examination: 

S1, S2 sounds are heard. 

No murmurs, apex beat heard at left 5th ICS, medial to MCL.

Respiratory system examination: 

Normal vesicular breath sounds heard. 

Bilateral air entry present. 

Investigations: 

Complete Blood Picture :

Rental function test 

Complete urine examination

Ultrasound Abdomen :

Chest  X - Ray :

Medication used :

Provisional diagnosis:

Based on above findings my provisional diagnosis is  Chronic Kidney disease leading to uremic encephalopathy.