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This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent

Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input

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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

Age/Gender : 40 Years/Male

Address

Discharge Type: Relieved

Admission Date: 28/09/2022 02:14 PM

Diagnosis

CKD ON MHD

Case History and Clinical Findings

CHIEF COMPLAINTS-BILATERAL PEDAL EDEMA SINCE 1 YEAR

ABDOMINAL DISTENTION SINCE TWO WEEKS

ANURIA SINCE 1 WEEK

HISTORY OF PRESENTING ILLNESS-

PATIENT WAS APPARETLY ASYMPTOMATIC ONE YEAR AGO WHEN HE DEVELOPED BILATERAL PITTING EDEMA OF THE LOWER LIMBS. LATER HE DEVELOPED ANURIA SINCE AWEEK

PAST HISTORY-

KICIO CKD SINCE 7 1/2 YEARS.

K/C/O HTN SINCE THREE YEARS

TREATMENT HISTORY-ON MEDICATION FOR HYPERTENSION.

PERSONAL HISTORY-

APPETITE-NORMAL

DIET-MIXED

BOWEL MOVEMENTS-REGULAR

MICTURITION-ABNORMAL

NO KNOWN ALLERGIES

NO ADDICTIONS

GENERAL EXAMINATION-

PALLOR NO

ICTERUS-NO

CLUBBING NO

CYANOSIS-NO

LYMPHAEDENOPATHY-NO

EDEMA-YES

MALNUTRITION-NO

DEHYDRATION-NO

VITALS-

BP-130/80

PR-84/MIN

RR-18CPM

SPO2-99%

TEMP-98.4F

SYSTEMIC EXAMINATION-

CVS-S1S2+

RESPIRATORY SYSTEM-BAE+

ABDOMEN-BOWEL SOUNDS HEARD

CNS-NAD

2D ECHO

SEVERE CONCENTRIC LVH

EF-46%

TRIVIAL AR AMD MR

MODERATE TR WITH PAH

DILATED LA AND LV

MILD SYSTOLIC DYSFUNCTION

NO DASTOLIC DYSFUNCTION

IVC DILATED NON COLLAPSING

Investigation

CBP

HB 7.9 GM/DL

TC 5000 CELLS/MM3

PLT 1.87 LAKHS/MM3

SMEAR NORMOCYTIC NORMOCHRONIC ANEMIA

RFT

UR 65

CR 4.6

CA+2 9.6

P 2.5

NA+ 141

K+ 3.6

CL-102

SR. IRON 81 MCG/DL

HIV NEGATIVE

HBSAG NEGATIVE

HCV NEGATIVE

Treatment Given(Enter only Generic Name) 

1) SALT RESTRICTION TO LESS THAN 2.4GM PER DAY

2) FLUID RESTRICTION TO LESS THAN ONE LITRE PER DAY

3)TAB.NICARDIA 20MG PO/TID

4)TAB ARKAMINE 0.1MG PO/TID

5)TAB. SACUBUTRIL VALSARTAN 50MG POIOD

6)TAB LASIX 8OMG PO/BD

7)TAB OR OFER-XT PO/OD

8)TAB. MET XL 25MG PO/BD

9) INJ.ERYTHROPOETIN SUB CUTANEOUSLY AFTER EVERY DIALYSIS

Advice at Discharge

1) SALT RESTRICTION TO LESS THAN 2.4GM PER DAY

2) FLUID RESTRICTION TO LESS THAN ONE LITRE PER DAY

3)TAB NICARDIA 20MG PO/TID

4)TAB ARKAMINE 0.1MG PO/TID

5)TAB. SACUBUTRIL VALSARTAN SOMG PO/OD

6)TAB LASIX 8OMG PO/BD

7)TAB.OROFER-XT PO/OD

8)TAB. MET XL 25MG PO/BD

9) INJ.ERYTHROPOETIN SUB CUTANEOUSLY AFTER EVERY DIALYSIS

Follow Up

VISIT FOR DIALYSIS 3 TIMES PER WEEK

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 Decdaration: The medicines prescribed and the advice regarding preventive aspects of care, when and howto 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: 26/10/22

Ward: CKD

Unit: NEPHROLOGY

CASE REPORT:PRESENTING COMPLAINTS:

A 40 year male, Insurance agent and farmer by occupation, resident of Nalgonda presented to OPD with complaints of :-

1. Bilateral lower limb swelling since 8 years.

2. Breathlessness since 7 1/2 years. 

3. Abdominal distention since 2 months.

HOPI:

40 year male who was apparently asymptomatic 8 years ago, had complaints of bilateral lower limb swelling which was insidious in onset, initially till ankle, aggregated during walking and relieved on taking rest and elevation of limbs; progressed gradually till knee in a span of 6 months. Patient sought for consultation at nalgonda govt. Hospital and was diagnosed to be having renal disease and started on conservative management.

After 2 months patient started noticing decreased urine output, and sought for review consultation and used medications that is increasing his urine output. After 1 years of treatment patient started having breathlessness on exertion that was gradually progressed to breathlessness at rest, and he was rushed to hospital and initiated on hemodialysis as his serum creatinine was high ( data not available), having swelling of entire body and no urinary output. Initially dialysis was initiated through right IJV double lumen catheter and meanwhile he underwent Right bracheochephalic av fistula creation in hyderabad. After 2 months, he was initiated on hemodialysis via AV fistula.Patient was on Maintainence hemodialysis since 6 1/2 years. As per the details given by the patients. He had episodes of high blood pressure recordings (data not present) during intra-dialysis sessions and peri dialysis and was diagnosed to be having hypertension 3 years ago and started on medications. Initially dialysis sessions were done twice per week; over a year he was undergoing hemodialysis thrice per year;

Since last 5 months; patient was having breathlessness during sleep for which he sought for consultation at nephrologist in hyderabad and advised for CRRT. As the patient was financially low, he continued to undergo on Maintainence hemodialysis. Since 2 months patient having comlaints of abdominal distention; abdominal paracentesis was done which showed high SAAG high protein( data was absent).

PERSONAL HISTORY:

Moderatly built and poorly nourshied.

Mixed diet.

Appetite normal

Decreased urine output.

Regular bowel movements.

Chronic alcoholic started at the age of 20 years, consumes 180 ml of alcohol daily.

Chronic smoker started at the age of 16 years, initially 4 beedies per day which progressed to 12 to 15 cigerettes per day.

GENERAL PHYSICAL EXAMINATION:

Patient was conscious, coherent, cooperative.

Afebrile to touch.

Pallor present.

JVP Raised.

Distended abdomen.

Pedal edema of grade II.

VITALS:

TEMP 98.6 F PR: 90 bpm; BP: 130/80 mmHg; SpO2: 98 %@Room air; GRBS: 155 mg/dL.

CVS: S1,S2+; R/S: BAE+, Bilateral IAA crepts; P/A: Soft, Non Tender, Distended, BS heard; CNS: NAD.

Initial assesment: 

Laboratory investigations:-

Hb (gm/dl) 7.9 (NCNC) 

BLOOD UREA (mg/dl) 65

Sr.CREATININE (mg/dl) 4.6

eGFR (ml/min/1.72m²) 16 (IV) 

Sr.Na+ (mEq/L) 141

Sr.K+ (mEq/L) 3.6

Sr.Cl- (mEq/L) 102 

Sr. Ca+2 (mEq/L) 9.6

Sr. Phosphorus (mEq/L) 2.5

TOTAL BILIRUBIN (mg/dl) 0.92

DIRECT BILIRUBIN (mg/dl) 0.24

AST/SGOT (IU/L) 10

ALT/SGPT (IU/L) 14

ALP (IU/L) 229

TOTAL PROTEINS (gm/dl) 5.7

Sr.ALBUMIN (gm/dl) 3.4

Sr. Fe (mcg/dl) 81

Usg abdomen 

RIGHT kidney 6.4x 2.5cms ,CMD LOST, PCS NORMAL

LEFT kidney 7.6 x 2.5cms, CMD LOST

PCS NORMAL

IMPRESSION B/L GRADE III RPD CHANGES

2D ECHO - 

At first assessment 

EF - 46%

SEVERE CONCENTRIC LVH

DILATED LV & LA

Mild LV Dysfunction

Grade I diastolic dysfunction 

No RWMA

No Pericardial effusion 

Mild TR with PAH, Trivial AR & MR

DIAGNOSIS:

1. STAGE V CHRONIC KIDNEY DISEASE

2. HFmEF; SEVERE CONCENTRIC LVH,  MILD LV DYSFUNCTION, GRADE I DD

3. HYPERTENSION 

Management:-

1) SALT RESTRICTION TO LESS THAN 2.4GM PER DAY

2) FLUID RESTRICTION TO LESS THAN ONE LITRE PER DAY

3)TAB.NICARDIA 20MG PO/TID

4)TAB ARKAMINE 0.1MG PO/TID

5)TAB LASIX 8OMG PO/BD

6)TAB OR OFER-XT PO/OD

7)TAB. MET XL 25MG PO/BD

8) INJ.ERYTHROPOETIN SUB CUTANEOUSLY 

BI WEEKLY

9) INJ. IRON SUCROSE 100 MG BI WEEKLY.

10) HENODIALYSIS 3 TIMES / WEEK.

FOLLOW UP ASSESMENT:

laboratory investigations:-

Hb (gm/dl) 9.3

TLC (cells/mm²) 9000

PLATELET (lakhs/mm²) 2.5

BLOOD UREA (mg/dl) 81

Sr.CREATININE (mg/dl) 3.8

eGFR (ml/min/1.72m²) 20 (IV) 

Sr.Na+ (mEq/L) 139

Sr.K+ (mEq/L) 4.5

Sr.Cl- (mEq/L) 100

Sr. Ca+2 (mEq/L) 4.4

Sr.Phosphorus (mEq/L) 2.0

TOTAL BILIRUBIN (mg/dl) 0.85

DIRECT BILIRUBIN (mg/dl) 0.14

AST/SGOT (IU/L) 13

ALT/SGPT (IU/L) 22

ALP (IU/L) 299

TOTAL PROTEINS (gm/dl) 6.3

Sr.ALBUMIN (gm/dl) 3.3

Sr. Fe (mcg/dl) 67

Follow up assesment of 2d echo:

EF - 38%

SEVERE CONCENTRIC LVH

DILATED Rt and Lt Atrium and Rt and Lt Ventricles

Moderate LV Dysfunction

Grade II diastolic dysfunction 

Regional wall motion abnormality - Global hypokinesia

Pericardial effusion - No

Valvular abnormalities - Severe TR with PAH, Mild AR & MR

Course in the hospital:

A 40 year male known case of Stage V chronic kidney disease on maintainence hemodialysis and HFrEF was clinically presented to casuality with above mentioned complaints. Necessary investigations were done, he underwent 2 sessions of maintainence hemodialysis on 22nd and 25th January; On 28th he was brought to casuality with complaints of altered sensorium since 1 day (27th January); History of fever spike since 2 days, which are of high grade associated with chills and rigors, relieved upon taking after antipyretic medication. His PR 50bpm; BP 110/80 mmHg; RR 22 cpm; GRBS 60mg/dl, for which 25% dextrose was infused, then GRBS was 208 mg/dl; GCS E3V3M5. His blood urea 127 and serum creatinine was 6.0, he was taken up for hemodialysis. His sensorium improved after hemodialysis and GCS was E4V4M6. His Blood urea 44 and serum creatinine 3.9 mg/dl. He underwent another hemodialysis session on 29/01/23. He underwent maintainence hemodialysis on 1st, 3rd and 5th February. On 04/02/2023 his Hb was 7.2 gr/dl; On 06/02/2023 at 12:16 AM, patient complained of sudden onset breathlessness, and was tachypnic; he was shifted to ICU and connected to ECG monitor, which showed ventricular fibrillation, immediately 360J of shock was deivered but as patient became unresponsive, central pulses were absent and BP was non recordable; immediately CPR was initiated according to ACLS guidelines and was intubated during CPR, CPR was continued for 30 minutes. Inspite of the above resuscitative efforts, the patient was declared dead at 12:59 AM, as ECG showed flat line with no electrical activity.

Management:-

1) SALT RESTRICTION TO LESS THAN 2.4GM PER DAY

2) FLUID RESTRICTION TO LESS THAN ONE LITRE PER DAY

3)TAB.NICARDIA 20MG PO/TID

4)TAB ARKAMINE 0.1MG PO/TID

5)TAB. SACUBUTRIL VALSARTAN 50MG PO/OD

6)TAB LASIX 8OMG PO/BD

7)TAB OROFER-XT PO/OD

8)TAB. MET XL 25MG PO/BD

9) INJ.ERYTHROPOETIN SUB CUTANEOUSLY 

BI WEEKLY

10) INJ. IRON SUCROSE 100 MG BI WEEKLY.

11) ALTERNATE DAY DIALYSIS.

DIAGNOSIS:

1. STAGE IV CKD ON MAINTAINENCE HEMODIALYSIS

2. HFrEF; SEVERE LVH; GRADE II DIASTOLIC DYSFUNCTION, SEVERE LV DYSFUNCTION 

3. HYPERTENSION 

OUTCOMES:

INTRA-DIALYTIC HYPOTENSION : NO

POST-DIALYTIC HYPOTENSION: NO

HYPOTENSION REQUIRING IONOTROPIC SUPPORT: NO

ACUTE CARDIOGENIC PULMONARY EDEMA: YES

ISCHEMIC HEART DISEASES: NO

EMERGENCY HOSPITALIZATION: YES

MORTALITY: NO