50 YEAR OLD FEMALE WITH CKD AND DENOVO HTN

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I’ve 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 .

 A 50 year old female who is a housewife residing at  suryapet Came to casualty with chief complaints of:

Loin pain since 1 year

Pedal edema since 7 days

HOPI :

Patient was apparently asymptomatic 5 years back , then she had a fall and sustained head injury (clot in brain according to pt and pt attenders) with severe headache for which she underwent surgery .

Patient complains of loin pain since 3 years which is Insidious in onset , gradually progressive , dragging type , radiating to lower abdomen, intermittent which aggrevated on working and relieved on taking medications ( NSAIDs - been using it since 2 years )

Patient has history of burning micturition since 3 months not associated with pain in lower abdomen, haematuria , vomitings.

Fever on and off since 3 months which is of low grade , intermittent , not associated with chills and rigor with no diurnal variations

Patient has pedal edema since 7 days , pitting type extending till knee joint 

No H/O shortness of breath , orthopnea  , PND.

Daily routine - She was a daily wage worker , but stopped working from 5 years after sustaining head injury .Stays at home since 5 years , does household works.

Past history:

Denovo HTN

Not a k/c/o DM , epilepsy, asthma, CAD

Personal history: 

Appetite - decreased since 3 months

Diet - Mixed

Bladder - burning micturition since 3 months 

Bowel habits - regular 

Sleep - decreased since 3 months

Family history: 

No similar complaints in the family 

General examination:

Patient is conscious, coherent, cooperative, well oriented to time , place and person 

Pallor - Present 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Pedal edema - pitting type extending till knee 

 

  VITALS :  Temp - 98.6 F

                  PR - 82 bpm

                 BP - 160/80 mmhg

                RR - 16 cpm

                SPO2 - 98% onRA

                GRBS - 119 mg/dl

Systemic examination: 

PER ABDOMEN:

Inspection :

          Abdomen is obese.

          Umbilicus is central and inverted

          All quadrants are moving equally with respiration 

          No scars , sinuses , engorged veins, visible pulsations .

          Hernial orifices are free.

Palpitation :

          Abdomen is soft and non tender 

          No organomegaly.

Percussion :

         Tympanic note heard over the abdomen.

Auscultation:

          Bowel sounds are heard.

CARDIOVASCULAR SYSTEM:

Inspection:

        Shape of chest is elliptical.

        No raised JVP

        No visible pulsations, scars , sinuses , engorged veins.

Palpitation:

        Apex beat - felt at left 5th intercostal space

        No thrills and parasternal heaves

Auscultation :

        S1 and S2 heard. 

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5

Reflexes    Right    Left

Biceps         ++         ++

Triceps        ++         ++

Supinator    ++       ++

Knee            ++       ++

Ankle           ++        ++

PROVISIONAL DIAGNOSIS :

CKD secondary to NSAID abuse with denovo HTN.

Investigations :

CBP :

         Hb – 8.2 gm/dl

         TLC – 7700cells/cu mm

         Neutrophils : 56

         Lymohocytes : 29

         Eosinophils : 07

         Monocytes : 08

         Platelets – 2.30 lakh/cu mm

Serum albumin - 3.9 gm/dl on 22/12/22

                           

Serum iron - 50 ug/dl

CUE :

         Albumin - ++++

         Pus cells - 2-3/HPF

         Epithelial cells - 2-3/HPF

Lipid profile :

        Total cholesterol - 182

        LDL - 108

        HDL-48

        TG -147

FBS :76 mg/dl

RENAL FUNCTION TESTS :

          Urea : 148 mg/dl

         Creatinine : 7.5 mg/dl

         Sodium : 137 mEq/L

         Potassium : 5.7 mEq/L

         Chloride : 107 mEq/L

LIVER FUNCTION TESTS :

         Total bilirubin : 0.84 mg/dl

           Direct bilirubin : 0.19 mg/dl

           AST : 10 IU/L

           ALT : 10 IU/L

           Alkaline phosphate :395 IU/L

           Total proteins : 5.6 gm/dl

           Albumin : 3.63 gm/dl

           A/G ratio :  1.84

CHEST X RAY:

ECG :

USG:

2D echo :

Treatment:

Salt restriction < 2 gm / day

Fluid restriction < 1.5 lit / day

Inj LASIX 40 mg IV BD

T. NICARDIA 10mg PO/TID

T. SHELLCAL 500 mg PO/OD 

T.BIO D3 PO/OD 

T.NODOSIS 500 mg PO/ BD

T. MET XL 50 mg PO/OD

FINAL DIAGNOSIS:

CKD secondary to NSAID abuse with denovo HTN with grade 1 fatty liver.