66 year old daily wage worker-
INTRODUCTION-
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to discuss our patient’s de-identified health data shared after taking his
signed informed consent. Here we discuss our individual patient’s 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
66-year-old male came to hospital with
complaints of-
Chief complaints- lower limb pitting edema, upper limb edema and fascial puffiness
since 5 days
History of present illness- apparently asymptomatic 5 days back, then developed lower limb
pitting edema progressing to upper limb. No H/O fever, vomiting, loose stool,
orthopnea, PND
History of past illness- Apparently asymptomatic 8 years ago, in 2013 he came to our
hospital with complaints of cellulitis and oliguria. Patient was admitted and treated
with skin graft surgery. At time of admission, serum creatinine and blood urea were
high along with hypertension. He got 3 sessions of hemodialysis. 3 months ago,
he took 3 tablets for hypertension (prazosin?), smoked a cigarette developing
right side hemiparesis. He went to a hospital in Khammam with complaints of right
hemiparesis, slurring of speech, deviation of mouth which recovered within 1
week.
General examination-
·
Pallor present
·
Cyanosis absent
·
Icterus absent
·
Clubbing absent
·
Lymphadenopathy absent
·
Pedal edema present
·
Malnutrition absent
·
Dehydration absent
·
Temperature- 98.4 F
·
Pulse rate- 75 BPM
·
Respiratory rate -24/min
·
BP- 220/130 mmHg
·
SpO2- 98%
·
GRBS- 127 mg%
Treatment history-
·
Hypertension- prazosin
Systemic examination-
·
CVS-
o
No thrills
o
S1, S2 +
o
No murmurs
·
CNS-
o
Conscious
o
No slurring of speech
o
No neck stiffness
o
Kernings signs absent
o
GCS- 15/15
o
Motor system- normal
o
Sensory system- normal
·
RS-
o
Dyspnea absent
o
Wheeze absent
o
Trachea central
o
Vesicular breath sounds
·
ABD-
o
Scaphoid
o
Tenderness absent
o
No palpable mass
o
Normal hernial orifices
o
No free fluid
o
No bruits
o
Liver- nonpalpable
o
Spleen- nonpalpable
o
Bowel sounds present
Investigations-
ECG- normal-
MRI Brain- ischemia and infarctions-
HBA1C, GRBS- normal-
Ultrasound abdomen- renal parenchymal
changes and prostamegaly.
Serum creatinine- raised-
Revealing high
serum creatinine, prostomegaly, renal parenchymal changes and infarcts in the
brain.
Provisional diagnosis- hypertensive urgency, anemia, anasarca, and AKI on CKD
Treatment-
·
1/10/21-
·
B+ PRBC transfusion
·
Fluid restriction- <1.5l/day
·
Salt restriction- <2g/day
·
Inj. Lasix 40mg IV
·
Tab. Nicardia 20mg
·
Tab. Clopidogrel
·
Tab. Atorvastatin
·
BP monitoring for 1 hr
·
2/10/21
o
Inj. Lasix
o
Tab. Nicardia
o
Tab. Clopridogel
o
Tab. Atorvastatin
o
Tab. Arkamine
o
Tab. Met-xl
o
Tab. Ecosporin
·
3/10/21-
o
Tab ultracet
o
Tab. Cilnidipine
o
Inj. Lasix
o
Tab. Nicardia
o
Tab. Clopridogel
o
Tab. Atorvastatin
·
4/10/21-
o
Tab ultracet
o
Tab. Cilnidipine
o
Inj. Lasix
o
Tab. Nicardia
o
Tab. Clopridogel
o
Tab. Atorvastatin
·
5/10/21-
o
Tab ultracet
o
Tab. Cilnidipine
o
Inj. Lasix
o
Tab. Nicardia
o
Tab. Clopridogel
o
Tab. Atorvastatin
·
7/10/21-
o
Tab ultracet
o
Tab. Cilnidipine
o
Inj. Lasix
o
Tab. Nicardia
o
Tab. Clopridogel
o
Tab. Atorvastatin
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