LONG CASE FINAL PRACTICAL EXAMINATION GENERAL MEDICINE.

- April 30, 2021

MEDICINE LOG BOOK BY VANDANAPU SAKETH:

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardians signed informed consent".

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

I've 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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

01/05/2021

long CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS

HALL TICKET NUMBER : 1601006192

A 34-year-old gentleman, from Motukur, who is a farmer by occupation, came to the hospital on 24/04/2021, for Maintenance Hemodialysis.

History of presenting illness :

Patient was apparently asymptomatic 3 years back when he was incidentally diagnosed with raised blood pressure of 200/110 mmhg for which he was put on medication.
Which he took for 4 months but wasnt compliant and stopped taking them thereafter and was asymptomatic for 7 months since then.
Patient started developing bilateral pedal edema since 13 months, insidious in onset, pitting type, associated with mild facial puffiness and decreased urine output since one year for which he came to the hospital and was put on maintainence dialysis for 10 months.
Patient complaints of abdominal distension and swelling of legs in between dialysis sessions.
No h/o burning micturition.
No h/o blood in urine.

Past history :

History of HTN since 3 years.
No history of diabetes , asthma, epilepsy, cardiac disease.

Family history:

Not significant.
No h/o HTN, DM, asthma, epilepsy, cardiac disease.

Personal history :

Diet- Mixed
Appetite- Decreased
Sleep- Adequate
B&B- regular
No addictions

General physical examination :

The patient is conscious, coherent and cooperative.
He is well oriented to time, place and person.
He is moderately built and moderately nourished.
There is presence of Pallor in the lower palpebral conjunctiva.
There is evidence of :
Facial and periorbital puffiness.
Bipedal edema which is of pitting type.
There is no Icterus, Clubbing, Cyanosis, Generalised lymphadenopathy.

Vitals :

Temperature : Afebrile
Pulse : 80 beats per minute, regular, normal in volume and character.
Blood pressure : 140/90 mm of Hg in the left arm.
Respiratory rate = 20 cycles per minute.
JVP is elevated to 11.5 mm of H20 at 45 degrees suggesting increased right ventricular pressures. ( probably volume overload due to reduced GFR )

Abdominal Examination :

On Inspection : The abdomen is mildly distended.
On palpation : The abdomen is soft and non-tender.
Shifting dullness is present.
Fluid thrill is absent.
Suggestive of Moderate ascites.

Examination of other systems :

Cardiovascular system : S1, S2 is heard. No murmurs are heard. JVP is elevated.
Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
Nervous system : Motor power tone and deep tendon reflexes are intact; sensations are normal. Cranial nerves are intact.

Clinical Pictures :

Elevated JVP