CODE CL

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, and investigations and coming up with a diagnosis and treatment plan.

DEIDENTIFIED DISCHARGE SUMMARY

PID : 202352109

UHID : 20231131562

Pay Type

Credit(AROGYA SREE)

Age/Gender: 76 Years/Female

Address

Discharge Type: Relieved

Admission Date: 20/11/2023 02:41 PM

Name of Treating Faculty

DR.SRI RAMULU(HOD)

Diagnosis

CHRONIC RENAL FAILURE

Case History and Clinical Findings

PATIENT CAME WITH CHIEF COMPLAINTS OF ITCHING ALL OVER BODY SINCE 15DAYS

C/O VOMITINGS SINCE 15 DAYS

PATIENT WAS APARENTLY ASYMPTOMATIC 15 DAYS BACK THEN DEVELOPED VOMITINGS, NON PROJECTILE FOOD AND WATER IN CONTENT, NON BILIOUS, NOT ASSOCIATED WITH FEVER,CHILLS,COLD,COUGH WITH NO AGGREVATING AND RELIEVING FACTORS,

H/O ITCHING ALL OVER BODY

NO HIO PALPITATION CHEST PAIN, SWEATING

NO HIO DYSPNEA, ORTHOPNEA PND

NO HIO BURNING MICTURATION

PAST HISTORY:

K/C/O HTN ON MEDICATION NIFEDIPINE 20MG

NOT A KIC/O DM, CAD, THYROID DISORDERS, EPILEPSY

GENERAL EXAMINATION:

PT IS CONCIOUS, COHERENT AND COOPERATIVE, MODERATLY BUILT AND NOURISHED.

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA

TEMP-AFEBRILE

PR-80BPM

RR-18CPM

BP-150/100MMHG

GRBS-147MG/DL

SYSTEMIC EXAMINATION:

CVS-S1,S2 HEARD, NO MURMURS

RS-NORMAL VESICULAR BREATH SOUNDS HEARD, NO WHEEZE AND DYSPNEA

P/A-SOFT, NON-TENDER, NO ORGANOMEGALY

CNS-NFND

DVL REFERRAL DONE:

DIAGNOSIS SENILE KEROSIS

PRURITIS SECONDARY TO CKD STAGE 5

PRURITIS SECONDARY TΟ ΑΝΑΕΜΙΑ

ADV:CEBHYDRA LOTION LIA BD X2WKS

Investigation

HBsAg-RAPID20-11-2023 04:21:PM

Negative

Anti HCV Antibodies - RAPID20-11-2023 04:21:PM

Non Reactive

RFT 20-11-2023 04:21:PM

UREA

250 mg/dl

CREATININE

8.3 mg/dl

URIC ACID

8.7 mg/dl

CALCIUM

10.1 mg/dl

PHOSPHOROUS

6.0 mg/dl

SODIUM

132 mEq/L

POTASSIUM

5.5 mEq/L

CHLORIDE

103 mEq/L

LIVER FUNCTION TEST (LFT) 20-11-2023 04:21:PM

Total Billurubin

0.56 mg/dl

Direct Bilunubin

0.19 mg/dl

SGOT(AST)

13 IU/L

SGPT(ALT)

8 IU/L

ALKALINE PHOSPHATE

194 IU/L

TOTAL PROTEINS

7.1 gm/di

ALBUMIN

4.4 gm/dl

A/G RATIO

1.63

RFT 22-11-2023 06:09:PM

UREA

267 mg/dl

CREATININE

9.5 mg/dl

URIC ACID

9.1 mg/dl

CALCIUM

9.4 mg/dl

PHOSPHOROUS

9.2 mg/dl

SODIUM

142 mEq/L

POTASSIUM

4.5 mEq/L

CHLORIDE

105 mEq/L

RFT 23-11-2023 07:32:AM

UREA

277 mg/d

CREATININE

9.2 mgidi

URIC ACID

9.0 mg/dl

CALCIUM

9.6 mg/dl

PHOSPHOROUS

8.0 mg/dl

SODIUM

13.3 mEq/L

POTASSIUM

6.3 mEq/L

CHLORIDE

102 mEq/L

RFT 23-11-2023 09:48 PM

UREA

202 mg/dl

CREATININE

8.4 mg/dl

URIC ACID

6.4 mg di

CALCIUM9.1 mg/dl

PHOSPHOROUS

7.8 mg/dl

SODIUM

134 mEq/L

POTASSIUM

6.1 mEq/L

CHLORIDE

99 mEq/L

RFT 26-11-2023 06:58:AM

UREA

114 mg/dl

CREATININE

5.4 mg/dl

URIC ACID

2.6 mg/dl

CALCIUM

8.8 mg/dl

PHOSPHOROUS

5.7 mg/dl

SODIUM

132 mEq/L

POTASSIUM

4.6 mEq/L

CHLORIDE

98 MEQL

RFT 28-11-2023 07:07 AM

UREA

160 mg/dl

CREATININE

7.5 mg/dl

URIC ACID

4.2 mg/dl

CALCIUM

8.2 mg/dl

PHOSPHOROUS

7.5 mg/dl

SODIUM

132 mEq/L

POTASSIUM

4.6 mEq/L

CHLORIDE

94 mEq/L

23/11/23

HB-5.9

TLC-7500

RBC-2.29

PLT COUNT-2.48

2D ECHO DONE:

IMPRESSION:MILD AR, MILD MR.TRIVIAL TR NO RWMA CONCENTRIC LVH,NO AS/MS

GOOD LV SYSTOLIC FUNCTION GRADE I DIASTOLIC DYSFUNCTION, NO LV CLOT Treatment Given (Enter only Generic Name)

T. LASIX 80 MG PO/BD

T. NIFEDIPINE 20 MG PO/TID

T. MVT PO/OD

INJ. IRON SUCROSE 100MG/TWICE WEEKLY

INJ. EPO 4000 IU SC/ONCE WEEKLY

Advice at Discharge

T. LASIX 80 MG PO/BD

T. NIFEDIPINE 20 MG PO/TID

T. MVT PO/OD

INJ. IRON SUCROSE 100MG/TWICE WEEKLY

INJ. EPO 4000 IU SC/ONCE WEEKLY

Follow Up

VISIT FOR HEMODILAYSIS TWICE WEEKLY

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE, DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:

08682279999 For Treatment Enquiries Patient/Attendent Declaration: The medicines prescribed and the advice regarding preventive aspects of care when and how to obtain urgent care have been

explained to me in my own language

SIGNATURE OF PATIENT/ATTENDER

SIGNATURE OF PG/INTERNEE

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY

Discharge Date

Date:29/11/23

Ward:NEPHROLOGY

31. CASE REPORT:

76 year female, home maker resident of Nalgonda presented to OPD with complaints of 

1. Decreased urinary output since a month

2. Generalized itching since 15 days.

3. Nausea since 15 days

4. Breathlessness since 15 days.

HOPI:

76 year female who was apparently asymptomatic 5 years ago, had complaints of headache for which she sought for consultation at nearest area hospital and was diagnosed with Hypertension and started on Tab. Telmisartan 40mg once daily. She used the medications for a year and thought hypertension was undercontrol (decided by herself) and stopped using antihypertensive medication. Since a month she started noticing decrease in urinary output. No history of burning micturition. Since 15 days she was having complaints of generalized itching and nausea. 14 days ago she had 2 episodes of vomitings, food and water as content, non projectile, Non bilious, not associated with fever, cough, cold, pain abdomen; no aggrevating or relieving factors. She also had complaints of Breathlessness since 15 days, gradually progressive, on exertion, orthopnea present, no chest pain, postural nocturnal dyspnea, 

No history of palpitations, chestpain, sweating.

PAST HISTORY:

known Hypertensive since 5 years on Tab. Nifedipine 20mg OD. 

No other co-morbidities.

PERSONAL HISTORY:

Appetite decreased

Sleep adequate 

Bowel movements are regular

Decreased urinary output

No Addictions

General examination:

Patient is conscious, coherent and co-operative. 

Afebrile to touch

PR: 82 bpm

BP: 160/90 mmHg

RR22 cpm

SpO2 97% on room air

GRBS: 147 mg/dl

JVP raised

SYSTEMIC EXAMINATION:

CVS: JVP raised, S1 and S2 heard

R/S: BAE +

P/A : Soft, non tender, nonorganomegaly, bowel sounds heard.

CNS: E4V5M6, NO FND.

Initial assessment

Hb (gm/dl) 6.0 (NCNC)

BLOOD UREA (mg/dl) 250

Sr.CREATININE (mg/dl) 8.3

eGFR (ml/min/1.72m²) 4.7

Sr.Na+ (mEq/L) 132

Sr.K+ (mEq/L) 5.5

Sr.Cl- (mEq/L) 103

Sr. Ca+2 (mEq/L) 10.1

Sr. Phosphorus (mEq/L) 6.0

TOTAL BILIRUBIN (mg/dl) 0.56

DIRECT BILIRUBIN (mg/dl) 0.19

AST/SGOT (IU/L) 13

ALT/SGPT (IU/L) 8

ALP (IU/L) 194

TOTAL PROTEINS (gm/dl) 7.1

Sr.ALBUMIN (gm/dl) 4.4

CUE Albumin+2, Sugars-nil

Sr. Fe (mcg/dl) 48

Usg

RIGHT kidney 6.5 x 3.5 cms ,CMD PARTIALLY LOST

LEFT kidney 8.6x4.4 cms, CMD PARTIALLY LOST 

IMPRESSION    

BILATERAL GRADE 2 RPD CHANGES

2D ECHO - 

EF 64%

Mild concentric LVH

Dilated LV  

Good LV systolic function

Grade Diastolic dysfunction 

No RWMA

Minimal Pericardial effusion 

Mild AR ,Mild TR, Trivial TR

MANAGEMENT:

1. TAB. FUROSEMIDE 80 mg/PO/BD

2. TAB. NIFEDIPINE 20 mg/PO/TID

3. TAB. OROFER XT /PO/OD

4. TAB. SHELCAL CT/PO/OD

5. INJ. IRON SUCROSE 100mg/IV/ TWICE WEEKLY

6. INJ. EPO 4000IU/SC/ ONCE WEEKLY

7. TWICE WEEKLY HEMODIALYSIS 

Follow up assessment 

Hb (gm/dl) 8.0 (NCNC)

BLOOD UREA (mg/dl) 59

Sr.CREATININE (mg/dl) 5.8

eGFR (ml/min/1.72m²) 7.1

Sr.Na+ (mEq/L) 140

Sr.K+ (mEq/L) 3.5

Sr.Cl- (mEq/L) 99

Sr. Ca+2 (mEq/L) 10.1

Sr. Phosphorus (mEq/L) 3.5

TOTAL BILIRUBIN (mg/dl) 0.85

DIRECT BILIRUBIN (mg/dl) 0.20

AST/SGOT (IU/L) 12

ALT/SGPT (IU/L) 10

ALP (IU/L) 130

TOTAL PROTEINS (gm/dl) 6.0

Sr.ALBUMIN (gm/dl) 3.36

CUE Albumin+2, Sugars-nil

Sr. Fe (mcg/dl) 54

2D ECHO - 

EF 60%

Mild LVH

No Dilated chambers 

Good LV systolic function

Grade-1 LV diastolic dysfunction 

Septal hypokinesia 

Minimal Pericardial effusion 

Mild MR,AR Trivial TR with PAH

Septal e' = 6 cm/s

E = 48 cm/s

E/e' = 8

RWT= 0.451

OUTCOMES IN RELATION TO ADVERSE EVENTS AND COMPLICATIONS:

INTRA-DIALYTIC HYPOTENSION: NO

POST-DIALYTIC HΥΡΟΤΕΝSION: NO

HYPOTENSION REQUIRING IONOTROPIC SUPPORT: NO

ACUTE CARDIOGENIC PULMONARY EDEMA: NO

CARDIAC TAMPONADE: NO

ISCHEMIC HEART DISEASE: YES

ARRHYTHMIAS: NO

MORTALITY: NO

EMERGENCY HOSPITALIZATION: NO

 

MANAGEMENT :

1. TWICE WEEKLY HEMODIALYSIS 

2. TAB. TELMA 40 mg/OD

3. TAB. NIFEDIPINE 20 mg/TID

4. TAB. METAPROLOL 25 mg/OD

5. TAB. ECOSPRIN AV 75/10 /OD

6. TAB. SHELCAL CT/PO/OD

7. INJ. IRON SUCROSE 100mg/IV/ ALTERNATE DIALYSIS 

8. INJ. EPO 4000IU/SC/ONCE WEEKLY.

HFA-PEFF diagnostic algorithm 

Followup Echo:

Major Criteria:

1. Functional:

   Septal e' < 7 cm/s or lateral e' < 10 cm/s or Average E/e' ≥ 15 or TR velocity > 2.8 m/s (PASP > 35 mmHg)

      (septal e' = 6 cm/s, TR velocity < 2.8 m/s)

2 points.

2. Morphological:

   LAVI > 34 ml/m² or LVMI >=149/122 g/m² (m/w) and RWT > 0.42

      (RWT > 0.42 is 0.451) 2 points 

3. Biomarker (SR):

   NT-proBNP > 220 pg/ml or BNP > 80 pg/ml

     Not done

4. Biomarkers (AF):

   NT-proBNP > 660 pg/ml or BNP > 240 pg/ml

     Not done

Minor Criteria:

1. Functional:

   Average E/e' 9-14 or GLS < 16%

     (E/e' is 8)

2. Morphological:

   LAVI 29-34 ml/m² or LVMI > 115/95 g/m² (m/w) or RWT > 0.42 or LV wall thickness ≥ 12 mm

     (RWT > 0.42 is 0.451, Mild LVH). (1 point)

3. Biomarker (SR):

   NT-proBNP 125-220 pg/ml or BNP 35-80 pg/ml

     Not done

4. Biomarkers (AF):

   NT-proBNP 365-660 pg/ml or BNP 105-240 pg/ml

     Not done

Total Score: 5

Follow-up Echocardiogram:

  Major Criteria: 4 points (RWT > 0.42, septal e' <7cm/s)

  Minor Criteria: 1 points (1 for mild LVH)

Total score: 5 points

According to the HFA-PEFF diagnostic algorithm:

 ≥ 5 points: HFpEF

2-4 points: Requires diastolic stress test or invasive hemodynamic measurements.

As this patient has a score of 5 points, the patient falls into the category of HFpEF.

DIAGNOSIS:

1. STAGE V CKD ON HEMODIALYSIS 

2. HFpEF, CAD- LAD TERRITORY, MILD MR, MILD AR, TRIVIAL TR WITH PAH, MINIMAL PERICARDIAL EFFUSION 

3. HYPERTENSION 

4. ANEMIA OF CHRONIC DISEASE