45 YEAR OLD FEMALE WITH METABOLIC SYNDROME (DM, HTN, HF, CKD)

 MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  


A 45 year old female daily wage labourer from kattangur was brought to ER on 23-04-2023 with chief complaints of SOB since morning

Dating back to her childhood days her father died when she was 10 years of age (He had a tumour on the back of the neck ? Malignancy)

She was a daily wage labourer who used to work for 7-8 hrs daily.

Wakes at 6am - goes to work at 9 am & works in the field for 7 to 8 hrs - returns home at 6-7 pm - goes to sleep at 10pm

Married at the age of 20 - Husband auto driver

2 sons : elder son 24 yrs of age at present

Younger son died soon after birth (cause unknown)

Used to live happily with her family

6 yrs back one fine day she had giddiness for which she went to a local hospital where she was diagnosed with diabetes and was using OHA since then

1 year later she again felt dizzy & was diagnosed with HTN - on treatment since then

Since last 1 year her life was not on track as she started to have pedal edema on & off + bilateral knee pains bcz of which she is not able to do work as usual

4 months back she developed pedal edema, facial puffiness progressed to anasarca, loss of appetite & generalized weakness for which she went to a local hospital in nalgonda where she was diagnosed with renal failure and was given some medication

She felt symptomatically better until 10 days back when she again developed anasarca, low back ache & generalized body pains for which she visited our hospital and hemodialysis was advised 

But patient refused and went home due to personal problems

10 days later on 23-04-2023 afternoon hours she was again brought to our hospital with chief complaints of sudden onset SOB since morning

SOB grade-4 associated with orthopnea

No history of chest pain, palpitation, or syncope

No history of fever, cold, or cough

No history of decreased urine output or dysuria

No other complaints


PAST HISTORY:

Patient is k/c/o DM since 6 years and was on OHA (T.GLIMIPERIDE 1mg + METFORMIN 500mg OD)
K/c/o HTN since 5 years and was on treatment (T.ATENOLOL 50mg OD)
No h/o CAD, CVA, Asthma, TB, or Epilepsy


FAMILY HISTORY:

Mother has hypertension and diabetes


PERSONAL HISTORY:

Mixed diet & decreased appetite
Sleep adequate
No bowel and bladder disturbances
No addictions


GENERAL EXAMINATION : 

Patient was conscious, coherent & cooperative
Oriented to time, place & person
Heavily built & nourished
Pallor +
Pedal edema + b/l pitting type extending upto shin of tibia
No icterus, cyanosis, clubbing, koilonychia, lymphadenopathy








VITALS:
Pulse rate - normal volume, regular in rhythm,92 beats/min, normal character, no radio femoral, no radio-radial delay, all peripheral pulses were felt.
BP- 190/110 mmHg in both arms  
RR- 28 cpm
SpO2- 78% on RA - 92% on 12 lit O2
GRBS- 168 mg/dl


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

Inspection: 
Chest is bilaterally symmetrical 
No precordial bulge
Apex impulse visible in 6th intercostal space at midclavicular line 
No visible pulsations, sinus, scars, or dilated veins.

Palpation: 
All inspection findings are confirmed 
Apex impulse - felt in 6th intercostal space at midclavicular line 
No parasternal heave 
No palpable thrills

Auscultation: 
Mitral area - S1 and S2 heard, no murmurs
Aortic area - S1 and S2 heard ,no murmurs
Pulmonary area - S1 and S2 heard ,no murmurs
Tricuspid area - S1 and S2 heard ,no murmurs


RESPIRATORY SYSTEM:

Inspection:

Chest is elliptical & bilaterally symmetrical

Trachea appears to be central

Movements appear to be equal on both sides

No visible pulsations, sinus, scars, or dilated veins.

Palpation:

All inspection findings are confirmed
Trachea central
Movements equal on both sides
Transverse diameter > Antero-posterior diameter 
Apex beat felt in 6th intercostal space at midclavicular line 
Tactile vocal fremitus: equal on both sides in all areas

Percussion:

Resonant note heard in all areas

Auscultation:

Bilateral air entry present

Normal vesicular breath sounds were heard

Fine crepts heard bilaterally in mammary, infra mammary, axillary, infra axillary & infra scapular areas


PER ABDOMEN:

Obese abdomen

Midline inverted umbilicus

LSCS scar + over lower abdomen

No visible pulsations/engorged veins/sinuses

Soft, non-tender, no organomegaly, no free fluid

Bowel sounds present


CENTRAL NERVOUS SYSTEM:

HMF - Intact                                   R.        L.

MOTOR SYSTEM: Power:      UL 4/5      4/5

                                                   LL  4/5      4/5

TONE - Normal.

REFLEXES - B.    T.    S.     K.    A.   P.

               R.     +2  +2.  +1.   +2.   --.  Flexion.

               L.     +2. +2.  +2.   +2.   --.  Flexion.

CRANIAL NERVES - Normal.


PROVISIONAL DIAGNOSIS:

Acute LVF - Flash pulmonary edema ? secondary to CAD

Hypertensive emergency

Anemia ?secondary to CKD

K/c/o CKD since 4 months

K/c/o DM-II since 6 years & HTN since 5 years


INVESTIGATIONS:

December 2022

Hb: 6.5 gm/dl
Creatinine: 2.0 mg/dl
U.albumin: ++


23-04-2023








24-04-2023


Mild LVH+
RVSP: 46+10=56mmhg
Mod TR with PAH
Good LV systolic function EF:57%
Diastolic Dysfunction+
IVC: 1.55cm, non collapsing



FINAL DIAGNOSIS:

Acute LVF - Flash pulmonary edema ? secondary to CAD

Hypertensive emergency

Severe anemia (NCNC) secondary to CKD

K/c/o CKD since 4 months

K/c/o DM-II since 6 years & HTN since 5 years



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