42Y/M C/o CKD 2* to Diabetic Nephropathy

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.

This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation

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 A 42 year old male working as a rice farmer , hailing from Nalgonda presented to the OPD with shortness of breath , loss of consciousness 2 days ago

history of Present illness 

patient was apparently asymptomatic 15 years ago

15 years ago , he had complaints of polyuria , nocturia , polyphagia , polydispsia and dizziness , he went to a government hospital and he was diagnosed with DM 2 , he reported that he is taking the prescribed  medication regularly .

5 years ago he had dragging type of pain at the back of head , he went to a local hospital where he was diagnosed with HTN , pateint reports taking the prescribed medication regularly 

1 year ago he complained of  shortness of breath , pedal edema , weakness and dizziness after visiting a government hospital after a fainting spell , he had a creatinine level of 7 and was recommended to start dialysis 

the patient has been on dialysis for 1 year , 2 months ago he reported paroxysmal nocturnal dyspnoea 

2 days ago , during his routine dialysis , he had 3 episodes of vomiting and shortness of breath and was intubated 

history of past illness 

he is a known case of DM2 , HTN

he is n/k/c/o epilepsy , asthma , tuberculosis 

personal history

diet : mixed 

appetite : normal

occupation : rice farmer 

micturition : on a foleys catheter  

bowel movements : reduced 

addictions : reports intake of alcohol occasionally 

                       smoked cigarettes occasionally 

allergies : not known 

family history 

- elder brother and younger sister have DM 2

---------------------------------------------------------------------------

examination 

general examination 

pallor : present 

icterus : absent 

cyanosis : absent 

clubbing : absent 

lymphadenopathy : absent

pedal edema : present , pitting type pedal edema , reduces on rest and elevation





vitals :

pulse rate : 74bpm

rr : 22cpm

BP : 150/100 mmHg

systemic examination

CVS

-thrills : no

- cardiac sounds : S1 S2 heard

-cardiac murmurs : no

 Respiratory system 

position of trachea : central 

dyspnoea : present 

wheeze : no

PA 

normal 

CNS 

normal

on examination of nails 

he has onychomycosis 


JVP video 






INVESTIGATIONS 






provisional diagnosis 

chronic kidney disease secondary to Diabetic nephropathy 


Case update 1/07/2022

Today nephrology update


Icu bed 4


http://drkulkarnimd.blogspot.com/2022/06/42m-with-sudden-sob-and-pedal-edema.html


Day 1 : 

S - patient is off sedation & paralysis and moving all 4 Limbs and responding to commands (1 step )


O - bp 140/90 

Pr 82 cpm

RR 22 cpm

Spo2 97%

Cvs S1 S2 heard

RS - BAE PRESENT

E4VtM6









A - acute cardiogenic pulmonary edema 2to ?NSTEMI with ? Aspiration pneumonia


P - plan to extubate if criteria meets.


Case update : 2/07/2022

- The patient has been extubated and his ryles tube is scheduled to be removed today 

Icu bed 4


http://drkulkarnimd.blogspot.com/2022/06/42m-with-sudden-sob-and-pedal-edema.html


Day 4 : 

S - patient is off sedation & paralysis and moving all 4 Limbs and responding to commands 


On Over night T piece

Yesterday HD was taken


O - bp 130/90 

Pr 82 cpm

RR 22 cpm

Spo2 97%

Cvs S1 S2 heard

RS - BAE PRESENT

E4VtM6





A - acute cardiogenic pulmonary edema 2to ?NSTEMI with ? Aspiration pneumonia with CRF secondary to ?Diabetic nephropathy ?Nsaid induced nephropathy


P - plan to extubate as criteria met for extubation.


 

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