69 years male CKD 2°DM+HTN

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I have been assigned this case to develop my competency in reading and comprehending clinical data, including the patient's history, clinical findings, and investigations, in order to come up with a diagnosis and treatment plan.

Case taken by Sangha Mithra and M.sravanthi 

Case Summary:

Patient Information

69 year old male brought to casualty by his family members for dialysis

Cheif complaints: brought for dialysis 3 days ago

History of presenting illness:

Ten years ago, the patient was asymptomatic. However, over time, they developed generalized body pains, particularly in their lower limbs, which were attributed to work-related stress. The pain would worsen during physical activities and required daily painkiller medication for relief.

Five years ago, the patient's condition deteriorated. They experienced generalized weakness, leading them to quit their pottery work. Alongside this, they began suffering from shortness of breath, initially at grade 2, with a gradual and progressive worsening to grade 4.

Four years ago, during a routine checkup, the patient was diagnosed with hypertension. They were prescribed antihypertensive medication to manage the condition. Two years prior to the hypertension diagnosis, the patient had a dog bite on their right calf, which did not heal despite receiving vaccination. As a result, the wound persisted for two years, necessitating approximately 13 additional vaccinations. Subsequently, the patient was diagnosed with diabetes and initiated treatment.

Nine months ago, the patient's health further declined as they experienced decreased urine output. They were promptly taken to the hospital, where they received a diagnosis of chronic kidney disease (CKD). The medical professionals recommended maintenance hemodialysis (MHD) as part of their treatment plan.

Just three days ago, the patient visited the hospital for a dialysis session. During the procedure, hypotension was detected, leading to a referral to our hospital for continued care. Since then, the patient has completely stopped passing urine. Dialysis was performed successfully in our hospital, but the patient has been suffering from neck pain and decreased appetite for the past two days. Additionally, they experience immediate bowel movements after eating.

Past history:

He's a known case for hypertension since 4 years and using antihypertensive drugs

He's also known case for diabetes from 2 years after hypertension and under medication

And not a known case for asthma CVD CVA epilepsy and other co morbidities 

Family history: not significant

Personal history :

He takes mixed diet with decreased apatite from 9 months and sleep is disturbed with pain and bowel and bladder movements are decreasing from 9 months  

Addiction History:

- From the age of 15, the patient used to smoke "bedi" (a type of tobacco) and consume alcohol.

- Initially, they started with smoking 1 to 2 packets of "bedi" per day but eventually reduced it to 1 or 2 "bedi" per day.

- Regarding alcohol consumption, they started with toddy and later began occasionally drinking other alcoholic beverages, consuming around 90ml to 180ml at a time.

- The addictions initially stemmed from work-related stress and the money they obtained from their occupation.

- However, the patient eventually stopped these addictive behaviors due to the advice of doctors and their family members.

Daily Routine:

- Previously, the patient had a structured daily routine. They would wake up at 3 am in the morning and engage in both work-related events and personal tasks until 7 am.

- At 7 am, they would have their main meal, which consisted of rice.

- From 7 am to 7 pm, the patient would have free time, likely not engaging in any specific activities.

- Dinner would be consumed at 7 pm.

- Following dinner, the patient would rest for the remainder of the day.

- However, after stopping work, the patient's daily routine changed. They began waking up around 3 or 4 am but did not engage in any specific activities at home. Instead, their day mainly revolved around eating and sleeping.

General examination :

 The patient is conscious, coherent, cooperative, thin-built, and malnourished.

- Examination performed in a well-lighted room

- Pallor present

 -icterus, cyanosis, clubbing, generalized lymphadenopathy, and bilateral pedal edema are absent.

Vital Signs:

- Blood pressure: 90/60 mmHg

- Pulse rate: 105 bpm

-temperature: 99.6 F

- Respiratory rate: 18 cpm

- Oxygen saturation (SpO2): 99% on room air

- GRBS - 106 mg%

Systemic examination:

Per abdomen:

Inspection:

 Shape of abdomen: flat

Umbilicus: Inverted and central

No visible pulsation, scars, swelling, sinuses, dilated veins .

Palpation: 

No local rise of temparature and tenderness 

Percussion: 

No fluid thrill, shifting dullness absent

Auscultation: 

Bowel sound heard 

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed.

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:No local rise of temparature and no tendersness

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs.