1801006069 - LONGCASE

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardian's signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.

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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

MED CASE:- 

A 50-year-old male patient farmer by occupation came to the casualty with the 

Chief complaints:- 

  - shortness of breath for 10 days 

  - complaints of edema in both upper and lower limbs for 6 days 

  - decreased urinary output for 6 days

HISTORY OF PRESENTING ILLNESS:- 

The patient was apparently asymptomatic till 2008; then he fell down from a tree while working in the field and he developed Backache which was persistent and relieved on rest (he did not use any medication for a year). After a year he used started using medication ( painkillers as said by the patient drug unknown; dose unknown; which relieved his pain but he stopped going to work. 

In 2016; the patient started having shortness of breath grade 2 and a high fever with chills and rigor, relieved by taking medication.

There was a history of dizziness and he was taken to a local government hospital where he was investigated and found to have 

DM - type 2 for which he was prescribed 

Metformin( dose - 500mg; no side effects are seen due to drugs) and he used them regularly with regular diet management and mild exercise.

Then after 3 years in 2019; he developed a fever with night sweats; chills; cough which contains sputum (color unknown); loss of appetite; loss of weight; then he was taken to a higher center where a sputum examination was done and was diagnosed with TUBERCULOSIS; and he was started on ATT which he used for 6 months regularly and after that, he was tested again and got negative. 

After 3 Years in May 2022, there was a minor accident with a fire and then he noticed that there was swelling in both legs he was investigated to see creatinine of 3.5 and diagnosed with CKD and was started on some medication ( drug unknown) 

But the swelling subsided for some days.

From then on he intermittently has pedal edema and shortness of breath.

In 2023 Jan he developed shortness of breath grade 3 and was rushed to a hospital, and said to have a heart; lung, and kidney abnormalities; and was admitted to the hospital for 2 weeks, where they gave him some medication, but did not use properly after on and symptoms persisted. 

10 days back he had sudden onset of shortness of breath which is GRADE IV, orthopnea present, and present

Edema of both upper and lower limbs For 6 days 

Lower limb edema which is pitting type (grade 4 ) up to the thigh.

In a private hospital And was referred to our hospital for further management.

PAST HISTORY:-

DM since 6 yrs ( metformin is used 500 mg) 

TB  3 yrs ago .

Not a known case of; Hypertension, thyroid,or Asthma. 

No history of any surgeries in the past. 

Drug history:- intermittent use of NSAIDS for the past 14 years. 

PERSONAL HISTORY:-

Diet - mixed 

Appetite normal 

Sleep - adequate 

Bowel - regular; decreased urinary output since 6 days 

Addictions - occasional alcohol ( Sara) before diagnosing diabetes, after that he stopped for some years and again started occasional alcohol for 2 years 

Cigarettes stopped 25 years back before 1 pack per year.

FAMILY HISTORY:-

no significant family history

 

ALLERGIC HISTORY:-

no allergies to any kind of drugs or food items

SOCIAL HISTORY:- 

Before 10 yrs he used to get up early in the morning go to his work which is 0.5 km from the house and come back in the evening. He used to have proper food. And sleep by 10:00 pm. 

He has no external stress factors. 

But after the injury to his back and after stopping his work he used to stay in the home whole day.

2 yrs back his daughter got married and after that he start drinking again.

Before he used to stay with his wife and daughter .now he stays with his wife .

GENERAL EXAMINATION:-

Date of examination:-  17/3/23

50-year-old male patient, supine decubitus who Is conscious, coherent, and cooperative 

comfortably lying on the bed, well-oriented to time,

place and person; well built and well nourished 

Pulse:  85 bpm

Rate, rhythm(regular)character(normal ), volume - normal 

peripheral pulsations [Carotid, brachial, radial, femoral, posterior tibial, dorsalis pedis]- present 

no radio radial delay 

BP: 120/80 mm Hg measured on Rt Upper arm In the supine position

Respiratory Rate:25 CPM; 

type- thoracic abdominal 

Temperature:- 96.9 F

SPO 2:- 98 %

GRBS:- 136 mg/dl

No pallor 

No icterus 

No cyanosis 

No clubbing

No lymphadenopathy

Edema present- bilateral  pitting type grade 4

JVP RAISED 

Video:- 

SYSTEMIC EXAMINATION:-

                                       AP:TRANSVERSE = 5:7

                            IMAGINARY PILLOW EFFECT

CARDIOVASCULAR SYSTEM:- 

INSPECTION:-

Appears normal in shape

Apex beat is not visible

No Dilated veins, scars, sinuses

PALPATION:

1- All inspector findings were confirmed.

2-Trachea is central.

APEX BEAT at 5TH INTERCOSTAL SPACE IN 1 cm LATERAL TO MID CLAVICAL

No palpable murmurs (thrills)

PERCUSSION:- 

 Heart borders are normal limits.

AUSCULTATION:-

S 1; S 2 heard in ALL THE AREAS 

RESPIRATORY SYSTEM:-

INSPECTION:- Chest appears symmetric

    No Dilated veins, scars, sinuses

PERCUSSION AND AUSCULTATION:-

PER ABDOMEN:- 

no tenderness

no palpable organs

bowel sounds - present

CNS EXAMINATION:- 

The patient is conscious. 

No focal deformities. 

cranial nerves - intact 

sensory system - intact

motor system - intact

INVESTIGATIONS:- 

7/3/ 23:- 

HAEMOGLOBIN %- 10.0 gms %

PCV :- 31.8 vol% 

8/3/23:- 

HAEMOGLOBIN - 11.3 gms % 

PCV :- 36.1 vol%

9/3/23:- 

HAEMOGLOBIN %- 11.0 gms %

PCV  - 34.5 vol%

SERUM CREATININE - 5.6 mg/dl.

10 /3/23 :- 

ULTRASOUND:- 

IMPRESSION:- B/L GRADE IN RENAL PARENCHYMAL CHANGES

B/L MODERATE PLEURAL EFFUSIONS

MILD ASCITES 

SERUM CREATININE

5.9 mg/dl 

SERUM POTASSIUM

3.4 mEq/L

HAEMOGLOBIN % - 10.6 gm 

PACKED CELL VOLUME:- 34.2 vol% ( decreased)

11/3/23:- 

SERUM CREATININE:- 5.9 mg/dL

Then referred to our hospital

13/3/23 :- 

Serology:

    HIV: NEGATIVE 

    Anti-HCV antibodies:- NON-REACTIVE

    HbsAg:- NEGATIVE 

    RANDOM BLOOD SUGAR: 125mg/dl

    CUE:- NORMAL 

    S.UREA: 64mg/dl (N:- 12-42mg/dl)

    S. CREATININE: 4.3 mg/dl

    S. Na+: 138

    S. K+: 3.4 (3.5-5.5)

    S. Cl-: 104

CBP:- 

    Hb:- 12.6 gm/dl

HbA1C: 6.5%

FASTING BLOOD SUGAR:- 93 mg/dl 

POST-LUNCH BLOOD SUGAR:- 152 mg/dl 

Liver function tests:-

Total bilirubin-0.9mg/dl

Direct bilirubin-0-1mg/dl

Indirect bilirubin-0.8mg/dl

Alkaline phosphatase- 221 u/l

AST-40u/L

ALP- 81u/L

ECG:-

Sinus tachycardia with VPCS .

X-RAY:-

ULTRASOUND:

2D echo:-

    Mild LV dysfunction-present

    MR +ve, TR +ve (moderate)

USG CHEST: 

IMPRESSION:

BILATERAL PLEURAL EFFUSION (LEFT MORE THAN RIGHT ) WITH UNDERLYING COLLAPSE.

USG ABDOMEN AND PELVIS:

MILD TO MODERATE ASCITES

RAISED ECHOGENICITY OF BILATERAL KIDNEYS

15/3/22 :- 

CBP:- 

    Hb:- 11.7 Gm/dl

    MCH:- decreased 

Blood urea:- 140 mg/dl 

serum creatinine:- 5.7 

Serum electrolytes:- potassium- 3.0 mEq/L

16/3/23 :- 

Hemoglobin - 11.4gm/dl

Lymphocytes -18%

PCV - 35.7

MCH - 26.7

RDW-CV - 19.6%

RBC COUNT - 4.27 MILLION/CUMM

BLOOD UREA -191 mg/dl {12-42}

Serum electrolyte 

Potassium - 3.1

Serum creatinine 5.7

17/3/2023:-

ECG:-

IMPRESSION:- LAD; SINUS TACHYCARDIA; Mild LVH

DIAGNOSIS:-

HEART FAILURE WITH MIDRANGE EJECTION FRACTION (EF:45%) 

WITH ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES/NSAID INDUCED)

WITH BILATERAL PLEURAL EFFUSION ( LEFT > RIGHT )

WITH MODERATE ASCITES

WITH K/C/O DM II FOR 6 YEARS

WITH OLD PULMONARY KOCHS(3 YEARS AGO)

TREATMENT:-

1. Fluid Restriction less than 1.5 Lit/day

2. Salt restriction of less than 1.2 gm/day

3. INJ. Lasix 40 mg IV / BD

4. TAB MET XL 25 mg 

5. TAB. CINOD 5 mg PO/OD(IF SBP MORE THAN 110 mm HG)

6. INJ. HUMAN ACTRAPID INSULIN SC/TID (ACCORDING TO SLIDING SCALE)

7. INJ. PAN 40 mg IV/OD

8. INJ. ZOFER 4 mg IV/SOS

9. Strict I/O Charting

10. Vitals Monitoring 

11. TAB. ECOSPRIN AV 75/10 mg PO

12. INJ. ERYTHROPOIETIN 4000 IU SC/ONCE WEEKLY

13. T.SODOCEL 500 mg/PO/TLD

14. SYP. POTKLOR 15 ml PO/TID

            8AM_2PM_8PM

Consent form:- 

Articles :- related to CHF and CKD  : 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999049/