A 37 y/o male came with complaints of pain in epigastrium

 Note : This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

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I have been given the following case to solve, in an attempt to understand  the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings,  Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

November 24 2021

Case recorded from November 18, 2021

(Under guidance of Dr. Durga Krishna sir, General Medicine PG)

CASE : A 37 Y/O MALE SUFFERING FROM CKD ON MHD WITH HYPERTENSION & ANEMIA 2° TO RENAL FAILURE

Initial Assessment :A 37 y/o male hailing from Nalgonda district, working as a farmer.

Chief Complaint : (Recorded in the words of the patient)

1) Pain in epigastric region.

2) Patient was asymptomatic 15 days back, associated with low grade fever.

3) Shortness of breath.

History of Present Illness :

1) The patient started having a pain in epigastric region 1 month back, which is non radiating, squeezing type.

2) It's not associated with giddiness, palpitations, sweating, syncope, blurriness of vision or blackout.

3) Shortness of breath is of Grade-2 (or) 3, of insidious onset and gradually progressive, only relieved on dialysis. 

4) Last dialysis was done on 17/11/2021 

Creatinine = 3.7

Urea = 40

Hb = 7.9

Past History :

History of Hypertension since past 25 days hence put on :

•  T. Nicardia 20 mg PO/TID
• T. Arkanine 0.1 mg PO/BD

Treatment History :

1) Diabetes : Absent

2) Hypertension : Diagnosed since 25 days

3) CAD : Absent

4) Asthma : Absent

5) Tuberculosis : Absent

6) Antibiotics : No history

7) Hormones : No history

8) Chemo/radiation : No history

9) Blood transfusion : No history

10) Surgeries : No history

11) Other : No history

Personal History :

1) Marital status : Married

2) Occupation : Farmer

3) Appetite : Normal

4) Diet : Mixed 

5) Bowel movement : Regular

6) Micturition : Normal

7) Other allergies : None known

8) Addictions :

• Alcohol intake : Occasional, but stopped after symptoms expressed.
• No other known addictions

Family History :

Not significant

GENERAL EXAMINATION

1) Pallor : Not seen 

2) Icterus : Not seen

3) Cyanosis : Not seen

4) Clubbing of fingers/toes : Not seen

5) Lymphadenopathy : Not seen

6) Oedema of feet : Not seen

7) Malnutrition : Not seen

8) Dehydration : Not seen

9) Temperature : Afebrile

10) Heart rate : 88 BPM

11) Respiratory rate : 22 breaths/min

12) B.P : 150/90 mm of Hg

13) sPO2 : 100% 

SYSTEMIC EXAMINATION

(1) CVS

1. Thrills - None
2. Cardiac sounds - S1, S2  (+)
3. Cardiac murmurs - none

(2) Respiratory System

1. Dyspnoea - None
2. Wheeze - None
3. Position of trachea - Central
4. Breath sounds - Vesicular
5. Adventitious sounds - None

(3) Abdomen

1. Shape - Scaphoid
2. Tenderness - Not seen
3. Palpable masses - None
4. Hernial orifices - Normal
5. Free fluid - Not seen
6. Bruits - None
7. Liver - Not palpable
8. Spleen - not palpable
9. Bowel sounds - Normal
10. Genitals - Normal

(4) CNS

1. Level of consciousness - Conscious
2. Speech - Normal
3. Signs of meningeal irritation - None
4. Cranial Nerves, sensory system and motor system - Normal in functioning
5. Glasgow scale - 15/15
6. Reflexes :

                         Right.                              Left
Biceps.              2+.                                   2+

Triceps.               +.                                    +

Supinator           +.                                    +

Knee.                 2+.                                  2+

Ankle.                2+.                                  2+

--- Plantars - Flexor

7. Cerebral Signs :

1. Finger Nose coordination - Present
2. Knee-heel coordination - Present

Lab Investigations :

Provisional Diagnosis : CKD on Maintenance Hemodialysis (MHD) with HTN & Anemia, 2° to Renal Failure

Treatment regime : 

1. Fluid restriction : Less than 1.5 L/day
2. Salt restriction : Less than 2.4 gm/day
3. Tab. NICARDIA 20 mg PO/TID
4. Tab.ARKAMINE 0.1mg PO/TID
5. Tab. LASIX 40 mg PO/BD
6. Tab. SHELCAL-CT PO/OD
7. Tab.OROFER-XT PO/OD
8. Tab.PANTOP 40 mg PO/OD
9. Inj. ERYTHROPOIETIN 4000 IU s/c weekly once.