59 K. Rithika Vasantha
E-LOG GENERAL MEDICINE
Hi, This is Rithika, a third semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.
A 75 YEAR OLD MALE PATIENT WITH CHRONIC KIDNEY DISEASE ( CKD)
Note:This is an ongoing case , the e-log will be updated as and when we find new information.
This e-log has been made under the guidance of Dr. Tejaswini.
Date of admission: 01.07.2021
CHIEF COMPLAINT:
On 1.7.21
A 75 year old gentleman was presented to the OPD with chief complaints of:
• Itching all over the body since 15 days
•Shortness of breath (grade III) -since 10 days ( dyspnoea on exertion)
• Pedal edema ( pitting type) - which was present since 1 year but got aggrevated in the past 10 days
HISTORY OF PRESENTING ILLNESS:
• Apparently, the patient was asymptomatic. till 1 year ago.
• 1 year back, he developed pedal edema (pitting type , intermittent, and gradual in onset) and has been on conservative treatment.
Aggrevated with alcohol or smoking.
•He was also diagnosed with hypertension a year back and was also on medication to treat it.
• Since the past 1 year, he complained of shortness of breath, which got much more aggrevated from the past 10 days.
It affected patient's daily routine : relieves on rest, medication and sitting position. Aggrevated during night time in sleep, he wakes up gasping for air, positional variation, where in supine posture aggrevation is seen, also aggrevated when patient smokes.
Associated with cough and mucoid sputum.
• He complains of itching all over his body since the last 15 days.
• He has no h/o fever and no h/o decreased urine output and burning micturition , no h/o altered sleep cycles. , no h/o of chest pain and palpitations.
HISTORY OF PAST ILLNESS:
The patient was a known case of :
• Scrotal swelling since past 20 years.
• UCD since the past one year and also had been on conservative treatment.
• Hypertension
• He sometimes complained of burning micturition .
• Not a k/c/O of DM, asthma, tuberculosis, stroke, CAD.
DRUG HISTORY:
• He has been on conservative drug treatment for pedal edema ( UCD) and hypertension for the past one year, but the name was not specified.
• No treatment history of Diabetes, CAD, asthma, tuberculosis, Antibiotics, hormones, Chemo radiation and blood transfusion.
PERSONAL HISTORY :
• No h/o of any altered sleep patterns.
• He follows a mixed diet and appetite is normal.
• Difficulty in passing stools since 1 month (only on alternate days).
• Normal micturition.
• He has been consuming alcohol occasionally ( in a much diluted form ) for the past 35-40 years,last drink was 2 months back.
• He has been smoking ( chutta) for the past 35-40 years, the last smoke was 10 days back.
FAMILY HISTORY :
• No family history of hypertension, diabetes, heart diseases, kidney diseases , asthma, Tuberculosis, cancers and stroke.
GENERAL EXAMINATION:
• Pt. is conscious, coherent, cooperative
• Moderately built and moderately nourished.
• Pallor present
• No icterus and cyanosis
• No lymphadenopathy
• Mild dehydration is present
VITALS: ( on 01.07.2021)
1. Temperature - 103°F
2. Pulse rate - 90 bpm
3. BP - 140/70 mmHg
( at 11 pm - 150/60mmHg )
4. Respiratory rate -
5. SPO2 at room air - 84 %
- 100 on 11lt
6. RBS - 101mg/dl
VITALS:( on 04.07.2021)
1. Temperature : 98.4°F
2. Pulse rate : 98
3. BP : 160/100 mmHg
4 Respiratory rate : 24
5. SPO2 at ra - 94%
SYSTEMIC EXAMINATION :
A. CARDIOVASCULAR SYSTEM
On 1.7.21
• S1 and S2 heard
• On auscultation, rt. Side cardiac rub +
On 4.7.21
• No thrills
• No cardiac murmurs
B. RESPIRATORY SYSTEM
On 1.7.21
• Wheezing sounds heard on auscultation of right lung.
• BAE +
On 4.7.21
• Vesicular breathing sounds present
• Trachea is central in position
• Dyspnoea present
C. EXAMINATION OF THE ABDOMEN
On 1.7.21
• soft, non - tender
• No complaint of abdominal tightness
• No organomegaly
On 4.7.21
• Scaphoid shape of abdomen
• No tenderness, no palpable mass, no free fluid, no bruits
• Hernial orifices - normal
• Normal bowel sounds
D. CENTRAL NERVOUS SYSTEM
•Pt. is conscious, coherent and cooperative.
• Speech is normal.
•No neck stiffness and kerning's sign
Cranial nerves, motor system and sensory system are normal.
• No focal neurological deficit.
PROVISIONAL DIAGNOSIS :
? CHRONIC KIDNEY DISEASE WITH NEED FOR DIALYSIS.
? CHOLELITHIASIS
? UREMIC PRURITIS ( RENAL PRURITIS)
INVESTIGATIONS:
On 1.7.21:
A. BIOCHEMICAL INVESTIGATIONS:
1. Serum Creatinine
2 . Blood Urea
3.Random Blood Sugar
B. PATHOLOGICAL INVESTIGATIONS
1.Hemogram
C. ULTRASOUND REPORT:
D. MICROBIOLOGICAL EXAMINATION:
• HBsAg - Rapid test - negative
• HIV 1/2 Rapid test - negative
• Anti HCV antibodies - negative
• SARS CoV2 PCR test - negative
On 4.7.21:
A. ABG REPORT
B. HEMOGRAM :
C. LFT :
D. RFT :
E. BLOOD GROUPING and RH TYPE :
F. SERUM IRON :
On : 6.7.21 :
A . ABG :
B. HEMOGRAM :
C. RFT :
D. ECG :
TREATMENT :
On 1.7.21
• head end elevation to treat SOB and tachypnoea
• NTG 1gm 4ml - for cardiac rub
On 4.7.21
• salt ( <2g/day) and fluid (<1l/day) restriction
• Inj. Lasix
• Tab. Nodosis
• Tab Shelca
• Tab Oeofex
On cross consultation : ( 4.7.21)
DVL : UREMIC PRURITIS
• Moisturex soft lotion
• Liquid paraffin
• Atarax anti itch lotion
Adviced for serum transferring saturation
DISCHARGE SUMMARY :
Chief complaints :
• Itching all over body since 15 days
• SOB - grade III since 10 days ( exertional dyspnoea)
• Pedal edema - pitting type, which was present since 1 yr , but aggrevated in past 10 days.
History of presenting illness :
• Pt was asymptomatic till 1 yr ago.
• 1 yr back, he developed pedal edema ( pitting type, intermittent and gradual in onset) and has been on conservative treatment. Which aggrevated with alcohol or smoking.
• He was also diagnosed with HTN a yr ago and was on medication to treat it.
• Since past 1 yr, he complained of SOB, which got aggrevated for past 10 days.
• It affected pt's daily routine ; relieves on rest, medication and sitting position. Got aggrevated during night in sleep, he wakes up gasping for air, positional variation, where in supine posture aggrevation is seen, also aggrevated when pt smokes.
• He complained of itching all over his body since 15 days.
• Has no h/o fever, decreased urine output, burning micturition, altered sleep cycles, chest pain and palpitations.
History of past illness :
• k/c/o
Scrotal swelling since 20 yrs,
UCD since 1 yr with conservative treatment
Hypertension
Sometimes, burning micturition
• Not a k/c/o DM, asthma, TB, stroke and CAD.
Drug history :
• Has been on conservative treatment for pedal edema (UCD) , HTN, for past 1 yr, but name not specified.
• No treatment history of DM, TB, asthma, hormones, antibiotics, chemo radiation and blood transfusion.
Personal history:
• No h/o altered sleep cycle.
• Follows mixed diet and appetite normal
• Difficulty in passing stools since 1 month(alternate days)
• Normal micturition
• Been consuming alcohol occasionally in a much diluted form for past 35-40 yrs, last drink was 2 mnths back.
• Been smoking ( chutta) for past 35-40 yrs, last smoke was 10 days back.
Family history:
• No family history of HTN, DM, heart diseases, kidney diseases, asthma, TB, cancers and stroke.
General Examination:
• Pt is conscious, coherent and cooperative
• Moderately built and moderately nourished
• Pallor present
• No icterus and cyanosis present
• No lymphadenopathy
• Mild dehydration present
Vitals (on 1.7.21)
• Temp. - 104°F
• PR - 90bpm
• RR - 22/min
• BP - 140/70mmHg
( at 11pm , 150/60mmHg)
• SPO2 - 84%
• RBS - 101mg/dl
Vitals (4.7.21)
• Temp - 98.4°F
• PR - 98bpm
• RR - 24/min
• BP - 160/100mmHg
• SPO2 - 94%
SYSTEMIC EXAMINATION:
A. Cardiovascular system:
On 1.7.21
• S1 and S2 heard
• On auscultation, rt. Side cardiac rub +
On 4.7.21
• No thrills and no cardiac murmurs
B. Respiratory system:
On 1.7.21
• wheezing sounds heard on auscultation of rt. lung
• BAE+
On 4.7.21
• vesicular breathing sounds present
• trachea is central in position
• dyspnoea present
C. Examination of the abdomen
On 1.7.21
• soft, non tender
• no complaint of abdominal tightness
• no organomegaly
On 4.7.21
• scaphoid shape of abdomen
• no tenderness, no palpable mass, no free fluid, no bruits
• hernial orifices - normal
• normal bowel sounds
D. Central nervous system
• Pt is conscious, coherent, cooperative
• NFND
PROVISIONAL DIAGNOSIS:
? CHRONICLE KIDNEY DISEASE WITH NEED FOR DIALYSIS
? CHOLELITHIASIS
? UREMIC PRURITIS
COURSE IN HOSPITAL :
Pt came to the OPD, on 1.7.21 , with complaints of itching all over his body, SOB and pedal edema. He also had cardiac rub on auscultation. So to treat that NTG was given. He had tachypnoea and SOB, and to treat that, head end elevation was done.
Again on 4.7.21 , he came again, when he was cross consulted with the dermatology dept, where he was treated for his pruritis. Further investigations were done, like serum creatinine, blood urea, blood sugar, hemogram, Usg, ABG report which suggested him having CKD WITH NEED FOR DIALYSIS, CHOLELITHIASIS AND UREMIC PRURITIS.
On 6.7.21 , LFT, RFT, we're also done and the patient was treated in the following manner :
On 1.7.21 :
• head end elevation to treat SOB and tachypnoea
• NTG - 1gm 4ml - for cardiac rub
On cross consultation :
DVL - UREMIC PRURITIS
• moisturex soft lotion
• liquid paraffin
• atarax anti itch lotion
On 4.7.21 :
On O/ E
• pt c/c/c
• spo2 - 97%
• RS : BAE +
• CVS : S1, S2 +
• P/A : soft, non tender
• CNS : Hmt intact
Rx followed :
• Salt and fluid restriction
•O2 inhalation if required
• Inj. Lasix 40mg
• Tab. Nodosis 500mg
• Tab. Shelcal 500mg
• Tab. Oeofex
• GRBS charting, 8th hourly
• strict I/O charting
• BP/ PR / SPO2 charting 4th hourly
On 5.7.21 :
On O/E :
• pt c/c/c
• temp - afebrile to touch
• BP : 120/70 mmHg
• PR : 90bpm
• SPO2 - 94%
• RS : BAE +
• CVS: S1, S2 +
• P/A: soft, non tender
• CNS : Hmt intact
same Rx followed as 4.7.21
On 6.7.21 :
Referred to Nephro.
On O/E :
• pt c/c/c
• temp : afebrile to touch
• BP : 110/70 mmHg
• PR : 92bpm
•CVS : S1, S2 +
• RS : BAE+ , NVBS
• P/A : soft, non tender
No organomegaly
BS +
• CNS : no FND
Rx followed:
• Tab. Sporolac
• ORS sachet
• along with Rx of 4.7.21 followed
On 7.7.21:
C/O loose stools yesterday, 10 episodes, paining sensation at Haley's site
On O/E :
• pt c/c/c
• temp - afebrile to touch
• BP - 100/70 mmHg
• PR - 90bpm
• sPO2 - 99%
• RS : BAE +
• CVS : S1, S2 +
• P/A : distended, non tender, BS +
• CNS : Hmf intact
Rx followed:
• salt and fluid restriction
• O2 inhalation if required to maintain SPO2
• Tab. Metrogyl 500 mg
• Inj. Lasix 20 mg
• Tab. Sporolac. ds
• Tab. Nodosis 550 mg
• Tab. Shelcal 500 mg
• Tab. Orofex XT
• ORS sachet
• strict I/O charting
• BP/PR/ SPO2 charting -4th hourly
• GRBS charting -8th hourly
• Moisturex soft lotion
• liquid paraffin
Links with relevant information:
THANK YOU
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