final practical medicine long case

This is an online E-log entry blog to discuss and understand the clinical data analysis of a patient, to develop competency in comprehending clinical problems, and providing evidence- based inputs in order to come up with a diagnosis and effective treatment plan to the best of my ability.

Registration number-1701006182
Case
Chief complaints:
A 30 year male auto driver by occupation presented to opd with chief complaints of
      Shortness of breath since 4days
      Decreased urinary output since 3 days
      Fever since 3days
      Swelling of feet since 3days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 year ago when he developed shortness of breath,which was insidious in onset, gradually progressive from MMRC grade II to III, not associated with any other symptoms. The patient went to Suryapet for a consultation, where he was told that his kidneys were failing and was given medication for the same. He continued to take the medication for 6 months. 

On investigations in Suryapet, he was diagnosed with both Hypertension and Diabetes Mellitus.on irregular medication

Came to our hospital a month ago, with shortness of breath again, which was insidious in onset, grade IV MMRC. On coming to the hospital, he was diagnosed with kidney failure and Dialysed in view of acute pulmonary edema 5 times last month,creat was 5.6
And then discharged on 2/6/2022

4 days ago, he developed shortness of breath which was sudden in onset, grade IV MMRC. Aggravated on walking and relieved on taking rest. It was not associated with orthopneoa, paroxysmal nocturnal dyspnoea, or diurnal variations.

Additionally, he had decreased urinary output since 3 days . Earlier, he would urinate 6-8 times a day. It was not associated with burning micturition.

He also complained of swelling in the feet since 3 days, uptil his knee. 
No history of cough, chest pain, palpitations.

PAST HISTORY
No history of similar complaints in the past
K/c/o DM AND HTN since 1 year not on medication

PERSONAL HISTORY

Diet: Mixed 
Appetite: Decreased since 3 days
Sleep: Decreased since 3 days due to the shortness of breath
Bladder: Decreased urinary output since 3 days, has been urinating 2-3 times a day
Bowel: Regular
Regular consumer of alcohol since 10 years, drinks about a quarter 4 times a week
No other addictions

FAMILY HISTORY
No similar complaints in family

GENERAL EXAMINATION

Patient was examined with informed consent in a well lit room. 
Patient is conscious, coherent, co-operative and well oriented to time, person, place. 

Moderately built, well nourished.

Patient examined in supine position.

Pallor present

Pitting-type bilateral pedal edema present uptil the knee level

No signs of icterus, cyanosis, clubbing, lymphadenopathy.

VITALS
Temperature: Afebrile 
HR: 122beats per minute
BP: 150/100mmHg
RR: 22 cycles/minute

SYSTEMIC EXAMINATION 
RESPIRATORY SYSTEM

INSPECTION: 

Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations

PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt

PERCUSSION:
Resonant note heard over all areas

AUSCULTATION:
BAE positive
Bilateral coarse crepts heard 
Vocal resonance: resonant in all areas

CARDIOVASCULAR SYSTEM: 
On palpation,
-Apex beat diffuse
-JVP normal
-No precordial bulge 
-No parasternal heave
On auscultation, S1, S2 heard; no murmurs

PER ABDOMINAL EXAMINATION:
Soft, non-tender
No hepato-splenomegaly noted

CENTRAL NERVOUS SYSTEM:
No abnormalities detected
 
Investigations 
At admission
Creat:11.9
Urea:185
Hb:8.9
TLC:33200
Neutrophils-90%
Lymphocytes-6%
Eosinophils-0
Plt:4.89
Iron-67
Albumin-2.8g/dl
Patient was dialysed on 11/06/2022
post dialysis urea:118,creatinine- 8.4
Cultures sent ,report awaited

Fever chart 
2d echo
       Concentric LVH
Mitral and tricuspid vegetations+
EF-55%

Xray
ECG

Patient underwent dialysis on 11/6/22 and 13/6/22

12/06/22
Hb-7.7g/dl
Total count-26,900
Neutrophils-90%
Lymphocytes _4%
Eosinophils-0 
PCV-22.8(40-50)
MCV-67.6(83-101)
MCH-23
RDW-CV- 18.5(11-14)
RBC -3.37
PLATELET-2.4

RFT
Urea;118
Creatinine-8.4
Uric acid-11
Ca-9
P -5.9
Na -138
K-4.2
Cl-101

On 13/06/22
Hb-7.3
Tlc-21,500
Neutrophils-88%
Lymphocytes-6%
Platelet-1.4

Na-137
K-3.9
Cl-99
 
Blood urea-149
Serum creatinine-10

14/06/22
Diagnosis-CKD on MHD 2°to?infective endocarditis
C/o-shortness of breath
Investigations 
Blood urea-92
Hb-7.1%
TLC-29,3008
Na-136ΔΊ
K-3.9
Cl-98
Platelet count-95000
Serum creatinine-6

PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease on hemodialysis with Hypertension, Diabetes Mellitus since 1 year 2°to ?infective endocarditis 

TREATMENT PLAN:
-Inj. PIPTAZ 2.25gm IV TID
-Inj. LASIX 40mg IV TID
-Inj EPI 4000U SC weekly once
-T. Nicardia 20mg PO TID
-T. Nodosis 500mg PO BD
-T. Orofex XT PO BD
-T Shelcal 5000qg PO OD
-T. met XL 50mg PO BD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly

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