58 YEAR OLD MAN WITH RENAL FAILURE AND RECENT MI

-
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section.

58 Y/M WITH RENAL FAILURE AND RECENT MI, ?SPONDYLODISCITIS

58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days, worsened 1 day back, chest pain since 30 days ,facial puffiness since 30 days


History of Presenting illness - 
Patient was apparently asymptomatic 4 years ago

4 years ago - pt complained of giddiness, went to a local hospital and was diagnosed as Hypertensive, on regular medication since then T. Nicardia 10mg, T. Arkamine 0.1mg sos

2 years back Pt developed B/L pedal edema, progressed gradually to knees, diagnosed with renal failure and initiated dialysis weekly twice

Left upper limb swelling, gradually progressing to current size, since 4 months .
Also developed rt upper limb swelling since 4 days.
 Swelling in the left chest region, gradually progressing to current size, since 4 months
Back pain since 2 months, subsided on medication (T. Ultracet)

30 days back - developed
Shortness of breath ,

Grade II-III progressed to Grade IV since 30 days along with orthopnea .
Sob worsened 1day back, associated with dragging type of chest pain .came for dialysis last night.
Even after dialysis, chestpain did not subside
Ecg was done(18/01/22): ST elevations noted in V2,V3,V4

Repeat ecg done (on 19/01/22): 
ST elevations subsisded

C/o. generalized body pains
No c/o palpitations, giddiness, cold, cough, burning micturition


PAST HISTORY -

Known case of Hypertension since 4years on Tab nicardia 20mg OD
Not K/C/O TB, Epilepsy, Asthma, CAD.

Personal history:
Appetite- normal
Diet- mixed
Bowel movement- Regular
Alcoholic stopped 4 yrs ago
Non smoker


On examination:

Pt is C/c/c

No Pallor,Icterus,Cyanosis, clubbing,Lymphadenopathy

B/L pedal Edema(pitting type) present








Vitals
Pr:94bpm
Bp:120/80
Spo2:97% at RA
Temp - Afebrile



Systemic examination

CVS - S1,S2 +
RS - BAE + 
CNS - NAD
P/A- Soft, non tender


Investigations on 02/01/2022:

Repeat xray:

Serology - Negative
Ortho referral for back pain :



Investigations on 08/01/2022:

Serology: negative
Rft:
lft:

Ecg:

Xray on 21/01/2022:

Diagnostic pleural tap was done.

Post -pleural tap xray

Pleural fluid LDH 98
Serum LDH 294
Ratio-0.3

Pleural fluid protein-2.0
Serum total protein -5.9
Ratio-0.3

Total count -100cells
Differential count- 
80% lymphocytes
20% neutrophils

Transudative effusion



Ortho referral done



Provisional Diagnosis -
CKD on MHD
Heart failure secondary to coronary artery disease(recent lateral wall MI)
?Spondylodiscitis
Hypertensive since 4yrs
?left upper limb lymphedema (secondary to AV fistula surgery)



Treatment-
Fluid restriction (<1l/day)

Salt restriction (<2g/day)

T· LASIX 40 mg PO BD

T. Nicardia 20mg PO BD

T. ULTRACET 1/2 tab QID

T. OROFER-XR PO OD

T. SHELCAL-CT PO OD

T.SORBITE 5 mg PO/BD

T.CLOPITAB-A 75 mg OD

24/2/22
DAYCARE DIALYSIS ROOM

58Y/M, previously a labourer was advised and started on dialysis 3 years back with a frequency of two sessions each week. Pt is on Nicardia 10 mg for Hypertension which was diagnosed 4 years ago. 
S: c/o generalised body pains
b/l pedal edema+, sob grade 3

O: Pt is C/C/C 
Temp- afebrile
Bp- 130/80 mmhg
PR- 74 bpm
RR- 20 cpm
CVS- S1 S2 heard
RS - BAE+
CNS - NFND
P/A- Soft, Non tender

A: 
Renal failure
Heart failure secondary to coronary artery disease (lateral wall MI) 

His recent reports on 10/2/22
Urea: 91 mg/dl
Creatinine: 5.6 mg/dl
Hb: 10 gm/dl
Albumin: 3.2 gm/dl
Total Proteins: 5.8 gn/dl
USG abdomen:
B/L grade 2 RPD
Left gross pleural effusion
Right mild pleural effusion

P:
He is currently receiving his HD session 
T. Lasix 40mg/PO/BD
T. Nicardia 10mg/PO/TID
T. Shelcal PO/OD
Advised fluid restriction <1L/day
Salt restriction <2g/day

ECG on 10/2/22



Xray Chest PA view on 23/2/22


Clinical examination:





Comments

Post a Comment

Popular posts from this blog

MEDICINE CASE DICUSSION

-
42 Year old patient with multiple health events BY: NIVRUTHA RATNAPURAM, ROLL NO. 134 SOURCE MATERIAL:  http://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html I have been assigned this case to get a better understanding of the problems faced by this de-identified patient in order to improve my knowledge regarding her various ailments. With the history that the patient has given along with the lab investigations, thorough details of her treatment and her goals of hiking and her worry over her mental health more than her physical health, the problems in order of priority I have found are: 1. Frequent pain on her left side along with increased pain tolerance  2. Chronic fatigue 3. Swelling over face and abdomen 4. Oliguria 5. Migraine with aura 6. Sleep Problems and Mood Disorders MY UNDERSTANDING OF THE PATIENT'S PROBLEMS ARE: 1. FREQUENT PAINS There is history of multiple sprained ankles and knees since the age of four, with continued history of pai
Read more

A 70 YR OLD MAN WITH RECURRENT EPISODES OF SYNCOPAL ATTACKS

-
Image
LONG CASE HALL TICKET NO. 1601006149 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section. A 70 YEAR OLD MAN WITH RECURRENT EPISODES OF SYNCOPAL ATTACKS A 70 year old man, who is a Weaver from Nakrekal, was rushed to the ER at Kamineni Institute of Medical Sciences, Narketpally on 23/04/2021, following an episode of loss of consciousness for 1 minute that very same evening.  HISTORY OF PRESENTING ILLNESS: - Patient was apparently symptomatic earlier yesterday afternoon, then at 04:00 PM, when he was weaving clothes he had sudden o
Read more

A 13 YEAR OLD BOY COMPLAINTS OF HIGH GRADE FEVER

-
Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section. 13 YEAR OLD BOY COMPLAINTS OF HIGH GRADE FEVER SINCE 4 DAYS A 13 year old school going boy complaints of  - high grade fever since 4 days - vomitings since 4 days - giddiness ince 4 days - loose stools since 1 day Patient was apparently asymptomatic 4 days back then he developed fever associated with chillschills.  Complaints of vomiting since 4 days- 2-3 episodes/day with food particles as content Loose stools- 5 episodes in the past one day No history of burning micturition, m
Read more