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 .
45 year old male cane with the chief complaints of burning sensation of feet and tingling sensation in feet on and off since 2 months.
Timeline of events :
In OCT 2019:
Patient was apparently asymptomatic 3 years back , then he developed pedal edema , pitting type , extending till knee and decreased urine output since 20 days .Shortness of breath which was insidious in onset , gradually progressive of grade 2.
No H/O fever, facial puffiness , palpitations, burning micturition.
NOVEMBER 2019
Went to hospital and underwent tests.
High 24 hr urine protein showing 11376 mg/day.
Planned for renal biopsy due to high 24 hr urine protein .
Diagnosed as PLA2R mediated Membranous nephropathy.
At the same time patient was found to be HbSAg positive
Patient was referred to gastroenterologist I/v/o HbSAg ( for opinion about the contraindication for immunosuppression)
He underwent ANA-IgG , Anti dsDNA-IgG ,AFP
IN DEC 2019
Started on treatment ( ponticelli regimen)
IN JAN 2020
IN FEB 2020
Patient was on regular follow up .
On 5/4/20:
On 17/5/22 :
On 6/6/22 :
Patient was on regular medication since diagnosis till 4 months back . He stopped medication 4 months ago.
Now patient complains of burning sensation and tingling in the feet since 1 month , pedal edema till ankle since 1 month.
PAST HISTORY:
K/C/O HTN - on Tab TELMA 40 mg OD
Not a k/c/o DM , TB ,epilepsy, asthma , TB, CAD ,CVD.
PERSONAL HISTORY:
Appetite-Normal
Diet - Mixed
Bowel and bladder - regular
Sleep - Normal
General examination:
Patient is conscious, coherent, cooperative, well oriented to time , place and person
Pallor - Absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Pedal edema - pitting type extending till knee
VITALS : Temp - 98.6 F
PR - 80 bpm
BP - 130/80 mmhg
RR -22 cpm
SPO2 - 98% onRA
GRBS - 102 mg/dl
Systemic examination:
PER ABDOMEN:
Inspection :
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 ++ ++
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