A 45 YEAR OLD MALE , WITH CKD & A RECENT EPISODE OF INVOLUNTARY MOVEMENTS

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I have 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 45 year old male came to casuality with

Chief complaints : a single episode of involuntary movements involving both of his upper limbs sparing lower half of the body.

HOPI: patient was apparently asymptomatic 4 yrs ago, then developed

             - B/L pedal edema ( gradual in onset progressive and is of pitting type ).

             - Shortness of breath ( grade 3 or 4 not a/w orthopnoea, PND, giddiness, sweating , syncope also it got aggravated from past 15 days  ).

2 years back he had H/o fall which led to to left femoral fracture, it has been operated but he had to walk using support. This had taken a toll on his work ( farming ), which he inevitably had to stop.

   During the same time he had also been diagnosed with CKD and was suggested to follow up regularly. But the patient opted not to.

On 18th Nov 2021 patient had an episode of involuntary movements involving both upper limbs sparing the lower limbs ( it was of tonic type and lasted for 10 mins ), post ictal confusion lasted for 10 hours and no similar episodes after that.

Past History : There were no similar complaints in the                               past.

Family history : There were no similar compalints in the                                family.

Personal history : patient was in altered sensorium, and the details given by his aide are as follows 

 - profession --- farmer but stopped due to the fracture 

-appetite --- normal

-diet ---mixed 

-bowel and bladder movements --- regular

-alcohol consumption since 20 yrs (about 90-180 ml/day)

-no other bad habits were practised.

H/o NSAID abuse since 2 years

GCS : E-4 V-3 M-4

Temp: afebrile

PR- 88 BPM

RR- 30 CPM

SPO2 - 99

GRBS-229

CVS - S1 &S2 +

P/A - soft and non tender 

RS:- BAE+ , NVBS

CNS:- CNS:

HIGHER MENTAL FUNCTIONS- Normal

Memory intact

CRANIAL NERVES :Normal

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Gait: Walks with a limp

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Provisional diagnosis : CKD with HYPERTENSION,DM-II, SEIZURE Secondary to Uremia? Severe metabolic acidosiswith uremic encephalopathy?

Treatment: 

 - FLUID RESTRICTION (< 1.5L/day )

 - SALT RESTRICTION (<2.4 gm/day )

 - Inj. LASIX 6P mg IV/ STAT , 40 mg IV/BD

 - Inj. NAHCO3 50 meq IV/STAT 15 mins to 20 mwq in 50 ml NS ver 45 mins

 - GRBS monitoring