70/F WITH SWELLING OF BOTH LOWER LIMBS, FACIAL PUFFINESS, SOB

This is an a 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.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 



 PATIENT WAS BROUGHT TO CASUALTY WITH

C/O SWELLING OF BOTH LOWER LIMBS SINCE 20 DAYS

C/O FACIAL PUFFINESS SINCE 20 DAYS

C/O SHORTNESS OF BREATH SINCE 4 DAYS

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 20 DAYS BACK THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , PITTING TYPE

C/O FACIAL PUFFINESS SINCE 20 DAYS

C/O SOB SINCE 4 DAYS INSIDIOUS IN ONSET GRADE 4 NYHA GRADUALLY PROGRESSIVE

H/O ORTHOPNEA

H/O CHEST PAIN , FEVER, BURNING MICTURATION, ABDOMINAL DISTENSION

NO H/O ABDOMINAL PAIN

NO H/O PALPITATIONS, DECREASED URINE OUTPUT

PAST HISTORY:

K/C/O HYPERTENTION SINCE 15 YRS ON TAB AMLODIPINE 5MG PO OD

DM II SINCE 10 YRS ON TAB GLIMI M1 PO OD

H/O TB 30 YRS BACK USED MEDICATION , COMPLETE COURSE

N/K/C/O ASTHMA, CVA, CAD, EPILEPSY


PERSONAL HISTORY:

DIET:MIXED

SLEEP:ADEQUATE

BOWEL AND BLADDER:STOOL NOT PASSED SINCE 3 DAYS, DECRESED URINE OUTPUT

ADDICTIONS:ALCOHOL SINCE 20 YRS STOPPED 3 MONTHS BACK

APPETITE: DECREASED


GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON.

NO PALLOR,ICTERUS,  CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA.

VITALS:

TEMPERATURE:98.6

BP:180/90 MM HG

PR: 64 BPM

RR:18 CPM


SYSTEMIC EXAMINATION:

CVS:S1,S2 HEARD NO MURMURS.

RS:BAE +,NO MURMURS

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY

CNS:NO FOCAL NEUROLOGICAL DEFICITS.

NEPHROLOGY REFERRAL DONE ON 21/ 1/24 I/V/O INCREASED UREA AND CREATININE

ADVICE COLLAGEN PROFILE, URINE FOR  BENCE ZONE PROTEIN, REVIEW WITH REPORTS, CONTINUE SAME TREATMENT

INVESTIGATIONS:

RFT 17-01-2024 04:37:PM


UREA 78 mg/dl 50-17 mg/dl


CREATININE 4.0 mg/dl 1.2-0.6 mg/dl


URIC ACID 7.0 mg/dl 6-2.6 mg/dl


CALCIUM 9.7 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 5.0 mg/dl 4.5-2.5 mg/dl


SODIUM 133 mEq/L 145-136 mEq/L


POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L


CHLORIDE 94 mEq/L 98-107 mEq/L

 

LIVER FUNCTION TEST (LFT) 17-01-2024 04:37:PM


Total Bilurubin 0.65 mg/dl 1-0 mg/dl


Direct Bilurubin 0.19 mg/dl 0.2-0.0 mg/dl


SGOT(AST) 15 IU/L 31-0 IU/L


SGPT(ALT) 10 IU/L 34-0 IU/L


ALKALINE PHOSPHATE 145 IU/L 141-53 IU/L


TOTAL PROTEINS 4.9 gm/dl 8.3-6.4 gm/dl


ALBUMIN 2.7 gm/dl 4.6-3.2 gm/dl


A/G RATIO 1.20


COMPLETE URINE EXAMINATION (CUE) 17-01-2024 04:37:PM


COLOUR Pale yellow


APPEARANCE Clear


REACTION Acidic


SP.GRAVITY 1.010


ALBUMIN +++


SUGAR Nil


BILE SALTS Nil


BILE PIGMENTS Nil


PUS CELLS 3-6


EPITHELIAL CELLS 2-3


RED BLOOD CELLS Nil


CRYSTALS Nil


CASTS Nil


AMORPHOUS DEPOSITS Absent


OTHERS Nil

 

HBsAg-RAPID 17-01-2024 04:37:PM Negative


Anti HCV Antibodies - RAPID 17-01-2024 04:37:PM Non Reactive

 

ABG 17-01-2024 04:54:PM


PH 7.31


PCO2 29.8


PO2 73.4


HCO3 14.8


St.HCO3 16.4


BEB -9.9


BEecf -10.2


TCO2 31.5


O2 Sat 94.9


O2 Count 12.7


T3, T4, TSH 17-01-2024 11:59:PM


T3 0.36 ng/ml 1.87-0.87 ng/ml


T4 7.83 micro g/dl 12.23-6.32 micro g/dl


TSH 1.94 micro Iu/ml 5.36-0.34 micro Iu/ml

 

RFT 18-01-2024 11:47:PM


UREA 86 mg/dl 50-17 mg/dl


CREATININE 3.7 mg/dl 1.2-0.6 mg/dl


URIC ACID 6.8 mg/dl 6-2.6 mg/dl


CALCIUM 9.9 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 4.9 mg/dl 4.5-2.5 mg/dl


SODIUM 135 mEq/L 145-136 mEq/L


POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L


CHLORIDE 98 mEq/L 98-107 mEq/L


RFT 19-01-2024 11:50:PM


UREA 89 mg/dl 50-17 mg/dl


UREA 89 mg/dl 50-17 mg/dl


CREATININE 3.9 mg/dl 1.2-0.6 mg/dl


CREATININE 3.9 mg/dl 1.2-0.6 mg/dl


URIC ACID 6.6 mg/dl 6-2.6 mg/dl


URIC ACID 6.6 mg/dl 6-2.6 mg/dl


CALCIUM 8.0 mg/dl 10.2-8.6 mg/dl


CALCIUM 8.8 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl


PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl


SODIUM 120 mEq/L 145-136 mEq/L


SODIUM 130 mEq/L 145-136 mEq/L


POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L


POTASSIUM 2.6 mEq/L 5.1-3.5 mEq/L


CHLORIDE 80 mEq/L 98-107 mEq/L


CHLORIDE 94 mEq/L 98-107 mEq/L

 

RFT 20-01-2024 11:51:PM


UREA 97 mg/dl 50-17 mg/dl


CREATININE 3.6 mg/dl 1.2-0.6 mg/dl


URIC ACID 6.0 mg/dl 6-2.6 mg/dl


CALCIUM 8.3 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl


SODIUM 128 mEq/L 145-136 mEq/L


POTASSIUM 3.6 mEq/L 5.1-3.5 mEq/L


CHLORIDE 96 mEq/L 98-107 mEq/L


SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 21-01-2024 11:01:PM


SODIUM 114 mEq/L 145-136 mEq/L


POTASSIUM 3.8 mEq/L 5.1-3.5 mEq/L


CHLORIDE 81 mEq/L 98-107 mEq/L


CALCIUM IONIZED 1.16 mmol/L mmol/L

 

RFT 22-01-2024 12:22:AM


UREA 109 mg/dl 50-17 mg/dl


CREATININE 3.7 mg/dl 1.2-0.6 mg/dl


URIC ACID 5.4 mg/dl 6-2.6 mg/dl


CALCIUM 8.5 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 4.9 mg/dl 4.5-2.5 mg/dl


SODIUM 113 mEq/L 145-136 mEq/L


POTASSIUM 4.0 mEq/L 5.1-3.5 mEq/L


CHLORIDE 84 mEq/L 98-107 mEq/L


SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 22-01-2024 06:47:PM


SODIUM 113 mEq/L 145-136 mEq/L


POTASSIUM 3.4 mEq/L 5.1-3.5 mEq/L


CHLORIDE 98 mEq/L 98-107 mEq/L


CALCIUM IONIZED 1.23 mmol/L mmol/L

 

RFT 22-01-2024 11:09:PM


UREA 96 mg/dl 50-17 mg/dl


CREATININE 3.7 mg/dl 1.2-0.6 mg/dl


URIC ACID 5.0 mg/dl 6-2.6 mg/dl


CALCIUM 8.9 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 4.8 mg/dl 4.5-2.5 mg/dl


SODIUM 115 mEq/L 145-136 mEq/L


POTASSIUM 4.0 mEq/L 5.1-3.5 mEq/L


CHLORIDE 99 mEq/L 98-107 mEq/L


SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 23-01-2024 05:37:PM


SODIUM 113 mEq/L 145-136 mEq/L


POTASSIUM 3.9 mEq/L 5.1-3.5 mEq/L


CHLORIDE 79 mEq/L 98-107 mEq/L


CALCIUM IONIZED 1.08 mmol/L mmol/L

 

RFT 23-01-2024 11:42:PM


UREA 104 mg/dl 50-17 mg/dl


CREATININE 3.6 mg/dl 1.2-0.6 mg/dl


URIC ACID 4.6 mg/dl 6-2.6 mg/dl


CALCIUM 10.0 mg/dl 10.2-8.6 mg/dl


PHOSPHOROUS 5.1 mg/dl 4.5-2.5 mg/dl


SODIUM 115 mEq/L 145-136 mEq/L


POTASSIUM 3.2 mEq/L 5.1-3.5 mEq/L


CHLORIDE 99 mEq/L 98-107 mEq/L

 HAEMOGLOBIN  8.7gm/dl


TOTAL COUNT 13,500cells/cumm


PCV  23.0 vol %

M C V  77.7fl

M C H 29.4pg

M C H C 37.8%

RBC COUNT  2.96millions/cumm

PLATELET COUNT 2.92Lakhs/cu.mm

LIPID PROFILE ON 18/1/24

Total Cholesterol144mg/dl

Triglycerides137mg/dl

HDL Cholesterol# 33mg/dl

LDL Cholesterol79mg/dl.

VLDL27mg/dl

24 HR CREATININE 2G/DAY

24 HOURS URINARY PROTEIN4,182mg/day.

24 HOURS URINEVOLUME1,700ml
.


HAEMOGLOBIN# 7.6gm/dl


TOTAL COUNT 11,300cells/cumm

PCV 19.9vol %

M C V  76.8fl

M C H 29.3pg

M C H C 38.2%


RBC COUNT# 2.59millions/cumm


PLATELET COUNT3.5lakhs/cu.mm


SMEAR

HEMOGRAM

HAEMOGLOBIN# 5.7gm/dl

TOTAL COUNT# 10,600cells/cumm

NEUTROPHILS76%

LYMPHOCYTES# 11%

EOSINOPHILS02%

MONOCYTE# 11%

BASOPHILS00%

PCV# 16.4vol %

M C V83.2fl

M C H28.9pg

M C H C# 34.8%

RDW-CV12.4%

RDW-SD38.3fl

RBC COUNT# 1.97millions/cumm

PLATELET COUNT2.73lakhs/cu.mm

2D ECHO ON17/01/2024

EF 60%

LEFT ATRIUM MID DILATED

LEFT VENTRICLE DILATED ,CONCENTRIC LVH,

IVC COLLAPSING[1.49 CMS]

MODERATE MR +,  MODERATE AR+,  MODERATE TR+ WITH MILD PAH

NO RWMA, NO AS/MS, SCLEROTIC AV

GOOD LV SYSTOLIC FUNCTION ,DIASTOLIC DYSFUNCTION + , NO LV CLOT

REPEAT 2D ECHO ON 22/1/2024

NO RWMA,CONCENTRIC LVH,

MODERATE TR+ WITH  PAH

 MODERATE AR+, ECCENTRIC MR

NO AS/MS, SCLEROTIC AV

USG ABDOMEN

B/L GRADE I RPD CHANGES

LEFT SINGLE RENAL CORTICAL CYST

 

DIAGNOSIS:

70 YR FEMALE/ 80 KGS

1. STAGE V CHRONIC KIDNEY DISEASE

NEPHROTIC SYNDROME SECONDARY TO DIABETIC NEPHROPATHY?

RENAL AMYLOIDOSIS?

MYELOMA KIDNEY?

2. HEART FAILURE WITH PRESERVED EJECTION FRACTION

OPHTALMOLOGY REFERRAL DONE ON 22/1/24 I/V/O RETINOPATHY CHANGES DUE TO DIABETES

IMPRESSION:NO EVIDENCE OF DIABETIC RETINOPATHY

ADVICE: STRICT DIABETIC DIET, FUNDUS EXAMINATION  FOR EVERY 6 MONTHS

3. HTN/DM 2/CLD PULMONARY


TREATMENT:

FLUID RESTRICTION LESS THAN 1.5 LIT PER DAY

SALT RESTRICTION LESS THAN 2 GM PER DAY

INJ LASIX 40 MG IV BD

INJ PAN 40 MG IV OD

TAB TELMISARTAN 40 MG PO OD

TAB NICARDIA 5 MG PO SOS

TB AZYTANIX 5MG PO OD

TAB SHELCAL CT PO OD

TAB PREGABALIN 75 MG PO HS

SYP ARISTOZYME 10 ML TID

DYP DULCOLAX 15 ML HS

NEPHRO PROTEIN POWDER 3 SCOOPS IN MILK/ WATER TID

3- 4 EGGS PER DAY

TAB SEVALAMER 800MG PO TID

TAB ALDALTOME 50 MG OD

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