A 58 YR OLD MALE WITH CKD



This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

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 58 yr old male patient Daily worker by occupation Came to OPD on 11 January 4.57pm

CHEIF COMPLAINT:
Patient came to OPD 7 days ago with chief complaint of 
  Shortness of breath since 7 days 
  Cold & cough since 6 days

HISTORY OF PRESENT ILLNESS:
 - Patient was apparently asymptomatic 1 yr back, then he developed Shortness of breath, cough, pedal edema, decreased urine output, distended abdomen
- He was taken to hospital and diagnosed to have renal failure and heart failure 
- He was suggested dialysis but refused and was on conservative management
- SOB grade III relieved on sitting position ,increases while lying 
- orthopnea,chest pain, palpitations 
- cough,cold, fever 
- sputum is mucoid and froathy 

HISTORY OF PAST ILLNESS:
 Is a K/C/O HTN since 1 yr (on medication with clonidine)
Not a K/C/O DM, Asthma, CAD, Epilepsy

PERSONAL HISTORY:
   Diet : mixed
   Appetite: normal
   Sleep : adequate
   Bowel and bladder movements: regular
   addictions: Alcoholic stopped since 1yr
                            Beedi (1pack per day)
   No allergies

GENERAL EXAMINATION:
- Patient is conscious,coherent and cooperative
Well oriented to time and place 
- No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of fingers 

- pedal edema subsided


VITALS:
Temperature - 99F 
Pulse rate -96 bpm
Respiration rate -16cpm
Bp-140/80 mm Hg
Spo -96%

SYSTEMIC EXAMINATION:


🔹RESPIRATORY SYSTEM :

Wheeze:present
Dyspnoea: present 

INSPECTION :-
Chest movements: Bilaterally symmetrical
Trachea is central in position 
No scars 

 PALPATION:-

All inspiratory findings are confirmed
Vocal fremitus decreased
Trachea is central in position

 PERCUSSION:-
     Stony dull heard in left mammary region

 AUSCULTATION:-
 Breathe sounds : diminished on left side (mammary, infra scapular region)
  Vocal resonance :decreased 
   Added sounds : Crepts 

🔹ABDOMEN:

INSPECTION:
 shape of abdomen: distended 
 Free fluid :yes
 Umbilicus :Inverted
 No dilated veins 
 No scars and sinuses 

PALPATION:
Non tender
No Local rise of temperature 
No palpable Mass 
Spleen and liver not palpable 

AUSCULTATION:
Bowel sounds are heard 

🔹CNS :
- Speech is normal 
- cranial nerve: intact 

🔹CVS :
-S1, S2 are heard
- No murmurs
- Raised JVP


 
PROVISIONAL DIAGNOSIS:
  Heart failure
Chronic kidney disease
 

CLINICAL IMAGES:
INVESTIGATIONS:
  ECG:

 ultrasound:
Chest x - ray 




 

TREATMENT:
T.NODOSIS 500mg PO BD
T. LASIX 40 mg PO BD
T. OROFER XT PO OD
T. SHELCAL PO OD
Inj. Erythropoietin 4000 IU S/C weekly once 

DIAGNOSIS:
Chronic kidney disease
Bilateral pleural effusion 
Right heart failure
Anemia

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