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Niranjana M Name: Mr E Sex: Male Age: 46 Occupation: Security Guard Date: 25/9/13

*History was taken from a patient who was in confusion and data was triangulated as much as possible with the consulting doctor and medical records. Presenting Complaint: Arm and Leg swelling 2/12 ago with Chest Pain History of Presenting Complaint: Mr E was admitted at HSA 2 months ago (JULY) for bilateral and painless arm and leg swelling. The swelling had a sudden onset which occurred overnight. There was associated paresis with the swelling and it was firm, oedematous and heavy. Mr E had missed his monthly check-up for Chronic Kidney Disease (CKD) in July and got admitted later in the same month due to this swelling. (Diagnosis of CKD 2y ago) According to Mr E, his limbs swell up as such when he is non-compliant to the treatment given for CKD however recently this year, the swellings have occurred even when he is compliant to treatment. No changes in urinary habit and no hematuria present. Soon after the admission at HSA, he was transferred to Kluang Hospital for Hemodialysis. An occasional, left and central, stabbing, non-radiating chest pain rated about 7-8/10 (10 being the worst) is also reported. It began 1 year ago and is relieved by rest. Its triggered by no particular cause as it occurs even when Mr E is resting and watching Television. PND is also present for the past 2y and Mr E wakes up at night feeling breathless and using more pillows while sleeping did not reduce the SOB episodes waking him up. This chest pain was not reported to the consultant at any point. Past Medical History 1998: Work Related Accident (Factory) where his hands were trapped in a machine leading to amputation of 3 fingers on the Right hand and 2 fingers on the left. 2011: Diagnosis of Nephrotic Syndrome and Kidney Failure Provision of Diuretics and Peritoneal Dialysis. PC: - Intermittent vomiting on and off within a few minutes and upon walking short distances. Vomited little each time (1/2 cup full) and contents were mostly water and food, but no blood. Such episodes used to occur roughly 3 times a week and did not have any particular trigger or relieving factor. This is what brought Mr E to the hospital to get it checked - Lightheadedness but no passing out episodes - Feeling hot and flushed despite normal room temperature which was previously tolerable - Weakness and fatigue - Loss of appetite - No change in urine habits and no hematuria

Niranjana M Hypertension was asymptomatic and was not diagnosed up till the point of presentation with CKD. This uncontrolled hypertension could have been the primary cause of CKD. 2/12 ago: Presented at HSA with swelling of arms and legs and an exploratory laprotomy for traumatic peritoneal dialysis (PD) was done. There was also peritonitis with MRSA and was treated with Vancomycin. Since PD could not be continued, Mr E was transferred to Kluang Hospital to start on Hemodialysis. Upon check-up before starting on Hemodialysis, diagnosed to be Hepatitis B positive. Drug History Only diuretic medications taken are for Nephrotic Syndrome. (Drug names couldnt be retrieved from patient or records). Vancomycin given during MRSA sepsis. No OTC or traditional medications or supplements. No known allergies. Family History Mr E mentioned he is not married however his records said that he is. (Discrepancy may be due to his confused state) He has 5 siblings and none have them have any renal conditions or hypertension. All of them are healthy. Both parents passed away due to carcinomas, although we could not elicit from Mr E what cancer(s) it was. Social History Mr E has smoked till his admission 2/12 ago and has a 2.5 pack year history. He used to consume alcohol during special occasions and would limit himself up to about 6-8 units per occasion. He has not done recreational drugs and has not traveled anywhere in the past year or prior to the diagnosis of Nephrotic Syndrome. Mr E worked previously in a factory where he faced the accident. After that he has worked as a Security guard up till his admission 2/12 ago. He was living with his sister prior to admission as per his history and his medical records. He feels lonely and upset without a proper family to show concern for him. He relies on the social welfare association for financial assistance and shelter and has temporarily been asked to continue to stay on at his sisters place after discharge. He has quit his job due to the necessity of coming to the hospital for Hemodialysis about 3 times a week and thus is financially unstable. The social welfare association has provided him with the bus fare required to attend his weekly dialysis sessions. Systems Review: CVS: Chest pain, Orthopnea RS: GI: Decrease in appetite, Occasional heartburn (possibly a side-effect of PD) NS: Fatigue, Confusion

Niranjana M GU: No change in urine habits, no Hematuria MS: Weakness, inability to walk more than 10 metres, Back pain (possibly a side-effect of PD) ES: Weight loss of over 5kg over two weeks post-op DERM: Pruritis and patches of white, dry skin ICE Mr E does not know why the laprotomy was done for him and he is only aware that his kidneys have failed and he has to undergo dialysis as treatment. Beyond being confused, we could sense him being upset that he has no one to take care of him (especially while eliciting family history) and he was happy to have had a conversation with us. He looks forward to going back to his working life without having any more dialysis and thinks that if someone donates their kidney for him then his condition would get better. Examination Findings General Examination: Malnourished, Frail, Anorexic, Pale. Close Inspection: Confusion, Amputated fingers, AV Fistula (ausculatated bruits over it), Pulse 62, RR 20, JVP raised to 10.5cm of water, Eyes showed sclera discoloured to yellow indicative of jaundice and pallor of conjunctival mucous membrane indicative of anemia, Poor oral dentition, Tattoos on the chest (possibly linking to Hepatitis B), Bed sores on the back, Paramedian laparotomy scar, Distended abdomen and patches of dry skin on the legs. Palpation: Chest expansion reduced, no heaves and thrills, apex beat slightly deviated to about 1cm lateral to the mid-clavicular line at the 5th intercoastal space. No abdominal tenderness or guarding or masses. No organomegaly or aortic aneurysm. Kidneys were not ballotable. Shifting dullness could not be elicited however there was a slight fluid thrill elicited. Percussion: Resonant with normal cardiac and hepatic dullness Ausculation: Breath sounds were normal vesicular breath sounds with reduced air entry and no added sounds. Heart sounds were clear S1S2 sounds with no murmurs but S1 was significantly louder than S2 especially at the apex. No aortic or renal bruits. Normal bowel sounds.

Niranjana M Investigations Full blood count with U/E and LFT progressively since admission 2/12 ago; Significant findings: Low HB (Lowest: 8.48g/dL) Low Platelets (Lowest: 77.1 x 109/L) High Urea (Highest: 24.9mmol/L) High Creatinine (Highest: 679 mol/L) High Bilirubin (Highest 26.4 mol/L) GFR Lowest: 8.1ml/min Stage 5 CKD (ESRD) ECG showed left ventricular hypertrophy and a suspected posterior MI in July upon admission at HSA. Prolonged QT?? Summary A 72 year old, female patient presented with a 2 month history of cough and 5kg weight loss accompanied with a recent fever. With physical examination and CXR findings of a left upper lobe upper region consolidation, it is likely to be a community-acquired, bronchopneumonia. Differential Diagnosis Bronchopneumonia was diagnosed as CXR did not show a diffuse opacity through the left upper lobe and was just at the left upper zone of the CXR lung field. Perindopril is an ACE Inhibitor which could have caused the dry cough but this can be ruled out since cough accompanies fever and has progressively become worse. Tuberculosis could be suspected due to her old age and unintentional weight loss but ruled out as there were no night-sweats, no significant hemoptysis and cavitatory lesion found in the CXR. Nevertheless, it could only be confirmed with the Mantoux test. Lung Carcinoma (Pancoast Tumour), could be suspected due to her age, and unintentional weight loss accompanying progressive cough, chest pain and SOB, and also muscle wasting of small muscles in her hand(a feature of Pancoast Syndrome). However could be ruled out at the moment due to a CXR resembling more of a patchy pneumonia consolidation rather than a circumscribed opacity which is more likely the appearance of a carcinoma. Moreover, Pancoast tumours are accompanied by Pancoast syndrome features like Horners syndrome and shoulder pain radiating along C8, T1 dermatomes. Since they were absent, it could be ruled out. Management Plan Broad-spectrum antibiotic IV Augmentin given immediately. After sputum culture, when the pathogen is identified, a specific antibiotic like a third or fourth generation Cephalosporin and Vancomycin could be administered if the pathogen is Streptococcus Pneumoniae. Benedryl cough syrup administered for symptomatic relief. Date: 18th September 2013 Time: 11:00AM Signature: Niranjana