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.
FINAL MBBS PART-2 KNRUHS EXAMINATION
Roll number: 1701006195
CHIEF COMPLAINTS:
28 year old patient from Nalgonda, autodriver by occupation came to the OPD with the chief complaints of:
1. Shortness of breath since 4days
2. Decreased urinary output since 3 days
3. Fever since 3 days
4. Swelling of feet since 3 days
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. Upon taking the medication, the patient recovered. He continued to take the medication for 6 months.
Additionally, on performing investigations in Suryapet, he was diagnosed with both Hypertension and Diabetes Mellitus. Although he was prescribed medication, he did not take it and did not follow up for with a doctor later.
1 month ago, the patient developed shortness of breath again, which was insidious in onset, grade IV MMRC (SOB at rest). On coming to the hospital, he was diagnosed with kidney failure and advised hemodialysis in view of him having pulmonary edema. Over the span of a week and a half, he went through five rounds of hemodialysis, following which he went home on 2/6/22.
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 with him urinating 2-3 Times a day. 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.
He had a history of fever since 3 days, which was low grade, not associated with chills and rigors. No aggravating factors noted, relieved on taking medication.
No history of cough, chest pain, palpitations.
DAILY ROUTINE:
Although the patient is an auto driver by occupation, he has been driving on and off since 1 year owing to deterioration of his health, and stopped driving one month ago. Now he usually spends his day at home.
PAST HISTORY
No history of similar complaints in the past
K/C/O DM, HTN since 1 year, not on medication
K/C/O kidney failure since 1 year, medication taken irregularly, on MHD since one month
PERSONAL HISTORY
Diet: Mixed until 1 month ago, since then he is vegetarian
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 of whisky everyday
No other addictions
No known food or drug allergies
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 ankle level
No signs of icterus, cyanosis, clubbing, lymphadenopathy.
VITALS
HR: 122beats per minute
BP: 150/100mmHg
RR: 20 cycles/minute
Temperature: Afebrile
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
Supraclavicular and infraclavicular areas normal
Spinoscapular distance normal
No crowding of ribs
No kyphoscoliosis
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
Chest diameter: 5:7
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
BAE positive
Bilateral fine 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:
HIGHER MENTAL FUNCTIONS-
Normal
Memory intact
CRANIAL NERVES-
Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES
Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION
Normal function
No meningeal signs were elicited
EVALUATION:
Patient underwent a session of dialysis on 11/06/22, and again on 13/06/22.
2D ECHO findings:
Concentric LVH
Mitral, tricuspid valve vegetations +
EF: 55%
ECG:
Other investigations:
PROVISIONAL DIAGNOSIS:
Chronic Kidney Disease on hemodialysis with infective endocarditis with Hypertension, Diabetes Mellitus since 1 year
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 500mg PO OD
-T. met XL 50mg PO BD
-Salt and fluid restriction
-Vitals monitoring 4hourly
-GRBS monitoring 12 hourly
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