Case history

 

CASE HISTORY 8 

            This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .

A 15 year old male patient presented to the opd  4 days back with chief complaints of  : 

Shortness of breath since yesterday 

Orthopnea is present 

HISTORY OF PRESENT ILLNESS  : 

  

 patient was apparently asymptomatic before  one month back who is studying 9 th class with a normal routine of waking up and having breakfast and going to school 

 and then developed fever which got subsided after taking medication

After this he developed vomitings which are usually during night time generally after taking food vomitus is usually devoid of blood and presence of food particles is seen 

After consulting a near by hospital they got to know that he is suffering from kidney disease in which he got dialysis upto 10 times nearly .

Patient also complains of chest pain during shortness of breath 

PAST HISTORY  : 

patients complains of no similar complaints in the past 

Hytensive since 1 month and is on Tab . Amlong 5 mg 

No h/o of diabetes .

H/ o of blood transfusions 3 times one month back

No history of asthma

No history of epilepsy

No history of thyroid disorders .

No history of any surgeries in the past 

FAMILY HISTORY  : 

 There are no similar complaints in the family members .

PERSONAL HISTORY  : 

 Diet : mixed

Appetite: decreased 

Bowel and bladder : normal

Sleep : adequate 

No addictions of alcohol and  smoking 

TREATMENT HISTORY: 

 patient took medication for fever and vomitings which is given by the local hospital 

And also got dialysed nearly 10 times 

GENERAL EXAMINATION  : 

 Patient consent was taken and he is cooperative,  conscious , and well oriented to time and place 

And he is examined under well lit room. 

Pallor  - seen 

Icterus not seen

Clubbing  not  seen 

Cyanosis not seen 

Generalised lymphadenopathy not seen

Pedal edema not seen 

Vitals : 

Temperature : afebrile 

Pulse rate : 96 bpm

Respiratory rate : 24 cycles /min 

BP : 140/100 mm of Hg 

SpO2 : 86 % at Room air .

GRBS : 121 mg%

Systemic Examination: 

CVS: S1,S2 heard no murmurs

CNS: normal

RS :

Bilateral Air Entry - present 

Bilateral crepitations heard at IAA and ISA.              

No wheeze .

PA: 

Soft ,non tender 

Bowel sounds + 

CNS:

NAD 

PREVIOUS REPORTS : 

Investigations :

HEMOGRAM : 

Hb - 8.7

TLC - 7800

N - 50

L - 40

M - 05

E - 05

B -00

Pcv - 25.1

RBC - 3.19

Plt - 1.2

MCV -78.7

MCH -27.3 

MCHC - 34.7 

COMPLETE URINE EXAMINATION : 

Pale yellow 

Albumin - 3+

Sugar -Trace  

Pus cells- 6 to 8 

Epithelial cells -3to 4  

 FBS - 78

RFT : 

Creatinine - 9.2 

Urea - 119

UA - 5.5 

Na - 141

K - 5.6

Cl - 101

LFT : 

TB - 0.79

Db - 0.19

AST - 17

ALT - 10

ALP - 201

TP - 5.8

ALB - 3.4

A/G - 1.36

Chest x ray :

Tachypnoea :

ECG report :

        

Provisional diagnosis : 

      

                       Chronic kidney disease on maintenance hemodialysis 

Treatment : 

1. Tab Lasix  40mg po/ BID

2. Neb  with  duolin ,budecort -8th hourly 

3.Tab .Zoffer - 4mg  po /TID

4. Tab .Nodosis -500mg  po /BID

5. O2 inhalation  to maintain SpO2 

6. Tab orofer AT  po /BID

7.STRICT  I/O  CHARTING 

8. BP ,PR,RR CHARTING

9.  Tab Rantac  150 mg po /OID .

      Follow up : 

Patient is getting dialysis regularly 2 to 3 times a week and was alright

Patient again presented to the opd with chief complaints of fever and shortness of breath on 30th November 

Orthopnea is present .

Also complaints about vomitings regularly which is generally after intake of food which is devoid of blood only food particles are seen in the vomitus since 2 days 

Also complains of pain in the chest region when there is presence of sob 

He has hypertension for which he uses medication but the bp is fluctuating .

Suddenly there is a fall of BP to 60 mm hg which is systolic pressure and given IV 100 ml NS BROLOS  in which no improvement is seen for that and inj NOR - ADREN is given 6 ml / hr 

On that day the pulse rate is 104 BMI

GRBS is 160 mg / dl

SPO2 is 100% with nor - adren at 6ml / hr 

Monitoring of vitals is done every hourly 

Patient is also prescribed inj . Erythropoietin 4000 IU given S/C weekly once 

And also inj. Iron sucrose 100 mg in 100 ml NS once weekly 

Pulse rate is also high 

INVESTIGATIONS : 

TREATMENT  : 

1. Tab Lasix  40mg po/ BID

2. Tab telma 20 mg po/bd

3.Tab .metxl 25 mg/PO/bd 

4. Tab .nicardia 10 mg  po /od 

5. Fluid restriction less than 1 litre per day

6. Tab orofer AT  po /BID

7.salt restriction less than 2 g per day 

8. BP ,PR,RR CHARTING

9.  Tab shelcal - ct po /od .