This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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.
Following is the view of my case...
CASE
28 year old male who is a sales man in cloth store presented to casualty with seizures 15 days back and fever with chills and cough since 10 days
HISTORY OF PRESENT ILLNESS--
•Patient was apparently asymptomatic 11 months back ( Feb-2021) then he noticed weight loss of about 10 kgs within 1 month
•After 2 months(April-14th ) he consulted local doctor ,on investigations there was increased in creatinine levels and hypertension
•Then went to hyderabad for confirmation , and told to start hemodialysis
•Then he came to our hospital on (april-16) for treatment then he was tested positive for covid ,so no treatment was started.
•Then he came back on June 24th. then he was put on dialysis .
He was on regular dialysis from june 24th to September 19th, nearly 28 dialysis was completed .
•Then he decided to remove central line and shift to AV fistula , which was failed once , then he tried again so was not on dialysis for 3 months( september to december)
•Then he had SEIZURES 15 days back , where there was 3 episodes
- each episode of seizure lasted for 3 to 5 minutes, associated with unrolling of eyes and frothing from mouth , there was post icthal confusion for about 30 minutes after 1st episode and about 10 to 15 minute after 2nd and 3rd episode
-not associated with biting of tongue and involuntary micturition
-after 1st episode he was taken to nearby hospital for he was admitted and treated for 3 days and was discharged and then he had another 2 episodes of seizures one at 10:00 pm and other one at 3:00 amthen he came back to our hospital , again. he was started on dialysis
-he complaints of shortness of breath ( II- III grads) and fever ( low grade) , cough ( dry cough),associated with chills , decreased urine output, and decreased appetite and chest pain since 10 days
-not associated with burning micturition, hematuria, nausea, vomiting, loose stools, head aches, confusion, dizziness
PAST HISTORY--
•Known case of hypertension since 11 months
•Not a known case of diabetes, asthma, TB , any CHD
FAMILY HISTORY--
no significant family history
PERSONAL HISTORY--
▪Diet-mixed
▪ Appetite-decreased
▪Bowel movements-Regular
▪Bladder movements-Decreased since 10 days
▪Sleep adequate
▪Habits- he was alcoholic and stopped since 8 months, and not a smoker
GENERAl EXAMINATION--
▪Patient is conscious , coherent and cooperative and well oriented to time place
and person, moderately built and moderately nourished
- Pallor- present
-Icterus-absent
-Cyanosis-absent
-Clubbing-absent
-Lymphadenopathy-absent
-Edema- of right ankle and dorsum of foot
VITALS--
Temperature-98.6
Pulse rate-88 bpm
Respiratory rate-14 com
BP-160/100 mm h
Spo2-98%
GRBS-130 mg%
SYSTEMIC EXAMINATION--
▪CVS-- s1 ,s2 heard no murmurs
• RESPIRATORY SYSTEM- pleural rub heard on the left side of chest.
• ABDOMEN-- no tenderness seen, no palpable mass seen , not distended
CNS--
-Patient is conscious
-Speech -normal
-No signs of meningeal irritation
-SENSORY EXAMINATION,- touch, pain, vibration -present
-No muscle wasting seen
-Tone of muscles is normal
▪REFLEXES:-
• Deep tendon reflexes
Right. Left
Knee jerk. +2 +2
Ankle reflex +2 +2
Biceps. +2. +2
Triceps. +2 +2
Supinator. +2. +2
•Power
Biceps. 5/5. 5/5
Triceps. 5/5. 5/5
Extensors of knee
5/5. 5/5
Flexors of knee
5/5. 5/5
Exetnsors of hip
5/5. 5/5
Flexors of hip
5/5. 5/5
•Gait -normal
▪Coordination
- Finger nose test-able to perform
- knee heel test- able to operform
- Romberg sign- negative
INVESTIGATIONS--
22/12/21
2D ECHO
CBP:
HB : 5.6gm/dl
TLC: 4000cells/mm³
PLT: 1.99 lakh/mm³
ABG
PH: 7.12
PCO2: 13.1
HCO3:6.9
RFT::
UREA : 239mg/dl
CREATININE : 16.8
URIC ACID : 16.8
CALCIUM : 8.2
Na+: 145
K+: 5.7
Cl- 107
LFT
ALT : 08
ALP : 164.
23/12/21
25/12/21
27/12/21
PROVISIONAL DIAGNOSIS--
Uremic encephalopathy with chronic kidney disease on maintainence hemodialysis with hypertensive nephropathy
TREATMENT--
1) Fluid restriction( 1 ltr per day)
2)salt restriction( 2.4 g per day)
3)Tab NODOSIS( 550mg )PO/OD
4)Tab SHELCAL(500 mg) PO/OD
5)Tab OROFER Po/ OD
6)Tab LASIX 40 mg PO / BD
7)TAB NICARDIA 10 mg PO/BD
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