CASE REPORT#3

NAME ERMIAS NEMANI

ID NUMBER MDR/3478/02
DEPARTMENT INTERNAL MEDICINE
SUBMITTED TO DR. YEWONDOWESEN
DATE 14/01/ 05

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IDENTIFICATION

Name: Hailu Dagne Age: 40 Sex: M Occupation: Driver Religion: Orthodox

Address: Sebeta Date of Admission: 2/13/04 Ethnicity: Tigre

Department: Internal Medicine Ward: B-8 Bed No:814.5 Marital Status: Married

Date of Clerking: 18/12/04 Source of History: The Patient

Chief Complaint

Generalized body swelling and shortness of breath of 5 months duration and 4 months duration

History of Present Illness

This is a known hypertensive male patient for the past 10 years and is on unspecified oral medication
which he takes twice per day and known diabetic patient for 3 years taking unspecified oral medication
once per day on follow-up every month at St Paul Hospital was relatively well until 5 months ago at which
time he started to experience generalized body swelling. The swelling started from the feet then after a
month progressed to the level of knee. It is bilateral. After 2 months the patient noticed the swelling
involved the abdomen. Associated with this he developed bilateral intermittent flank pain which was mild.
He also developed decreased urine output which he started to notice since 2 months back. He also has
frequency, urgency but no urine discoloration or pain during micturition.

After a month since the onset of the swelling he started to developed shortness of breath while walking.
After few weeks he started to develop the shortness of breath even at rest. He also has orthopnea of 2
pillows and paroxysmal nocturnal dyspnea since 3 months back. Associated with these he developed
bilateral chest discomfort which does not radiate to any place. He has no pain during breathing. Otherwise
he has no palpitations or history of syncopal attack.

Since 3 months back he developed cough which was associated with whitish sputum. The sputum is
odorless and it is less than half a liter per day. The cough is usually exacerbated by cold and during the
night. He currently lives in Wolesso Maremia Bete as a prisoner since 10 months back and has occasional
contact with people who cough but does not know whether they have been diagnosed as TB or any other
respiratory problems. He has no fever, night sweats or hemoptysis. He has no self or family history of
asthma or any abnormal sound during breathing.

He has easy fatigability and change in sleeping pattern. He has history of epistaxis, headache, blurring of
vision and vertigo a year back. Otherwise he has:

- No family history of Diabetes Mellitus or hypertension.

- No self or family history of cardiac or liver diseases.

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 - No history of yellowish discoloration of the eyes or skin. No history of blood transfusion,
tattooing or contact with jaundiced person.
- No history of malaria or travel to malarious area.
- No history of excessive salt intake.
- No history of smoking, excessive alcohol intake or unprescribed drug intake.
- No history of abnormal body movement, loss of consciousness or memory loss. No history of
numbness or tingling sensations in the extremities.
- No history of trauma.
- No history of sore throat or skin lesions. No history of joint pain or swelling. No history of blackish
discoloration of the feet.
- No history of vomiting or diarrhea.
- His non-reactive for RVI.
- No changes in the nails.
- No history of pain in the calves while walking.

For the above complaints he was first seen at clinic in Wolesso Maremia Bete five months ago. He was then
told to have renal problem after urine and blood examination. He was on unspecified IV medication which
he took once a day. Due to unimproved conditions he was referred to Tikur Anbessa Hospital.

Previous Admission

-None

Past Illnesses

No chicken pox, mumps, measles or any other childhood diseases.

Functional Inquiry

H.E.E.N.T

Head: see HPI.

Ears: see HPI. Otherwise no loss of hearing, discharge or earache.

Eyes: SEE HPI. No strain, lacrimation, or itching.

Nose: See HPI. No discharge.

Mouse and throat: see HPI. Otherwise no dental pain or bleeding from the gums.

Glands: No enlarged masses over the neck, axilla or groin. No heat or cold intolerance.

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Respiratory System: SEE HPI.

Cardiovascular system: SEE HPI.

Gastrointestinal system: See HPI. No nausea, dysphagia, heart burn, constipation or abdominal pain.

Genitourinary system: SEE HPI.

Integumentary system: SEE HPI. Otherwise no dry hair.

Allergy: see HPI. Otherwise no drug sensitivity, hay fever or urticaria.

Locomotory system: see HPI. Otherwise no bony or joint deformities.

Central nervous system: SEE HPI.

Personal History

The patient is married and has children. His wife and his children are fine.

Family History

Father and mother: Both are alive and well.

Siblings: He has three brothers and three sisters which are all fine.

Family Diseases: SEE HPI.

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Physical Examination
General Appearance

The patient is chronically sick looking and is depressed.

Vital signs

BP: 110/80mmHg, right arm, sitting position.

110/ 80 mm Hg, right arm, standing position.

PR: 85 beats/min, radial artery, regular, full volume

RR: 19 breaths/min, shallow, regular rhythm

T0:36.30c, axillary

Weight: 90 kg

Height: 175 cm

BMI= 29.4 kg/m2

H.E.E.N.T

Head: No scar, swelling or area of tenderness. Normal hair distribution.

Ears: Normal contour of pinna. Clear external ear canal. No mastoid tenderness.

Eyes: Normal eyebrows. No per-orbital edema, ptosis, exophthalmoses or strabismus. The conjunctivae are
pink. No icteric sclera. No cataracts.

Nose: The nasal septum is not deviated. There is no polyp or unusual discharge.

Mouse and throat: No cyanosis over the tongue, lips or buccal mucosa. No dental caries. The gums are
intact. No oral thrush. No halitosis.

Lymphatic and glandular system

There are no enlarged lymph nodes over the occipital, posterior and pre auricular, anterior and posterior
cervical, sub-mandibular, sub-mental, supra-clavicular, axillary,inguinal and epithrochlear areas.

The thyroid is not enlarged. No lumps in the breast tissue. The testes are descended. No parotid swelling.

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 Respiratory System

Inspection: The chest is symmetrical. There are no deformities, surgical scars, visible pulsation or dilated
vessels.

Palpation: The trachea is central. There are no swellings or area of tenderness over the entire chest. Tactile
fremitus is decreased bilaterally and posteriorly below the scapula. Chest expansion is symmetrical.

Percussion: bilateral dullness posteriorly below scapula otherwise resonant over other areas of the chest.

Auscultation: decreased air entry bilaterally and posteriorly below the scapula. Vesicular breaths sound
over the lung fields. Otherwise no wheeze, pleural friction rub or basal crepitation.

Cardiovascular system

Arteries: BP and pulse (see under vital signs). There is no hardening of the vessel wall. Normal pulse volume
over the carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis. No radiofemoral
delay. No bruits over the carotid artery.

Veins: JVP is not raised.

Precordium

Inspection: There is no precordial bulge. The precordium is Quiet. The apical impulse is at fifth intercostal
space medial to mid-clavicular line.

Palpation: The point of maximum impulse is same as that of apical impulse. No palpable heart sounds. No
parasternal or apical heave. No thrill.

Auscultation: S1 and S2 are well heard. There are no added heart sounds (split, gallop, ejection click,
opening snap). No murmur.

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 Gastrointestinal System

Inspection: The abdomen is symmetrically distended. It moves with respiration. Flanks are full. Hernia sites
are free. No scars, distended veins or visible peristalsis.

Auscultation: The bowel sound is normo-active. There is no bruit over renal artery, abdominal aorta or liver
areas.

Palpation:

-Superficial palpation: no superficially palpable mass. No direct or rebound tenderness.

-Deep palpation: No tenderness. Liver and spleen are not palpable. Kidneys are not bimanually palpable.
No balotable organ.

Percussion: positive shifting dullness and fluid thrill. The total vertical span of the liver along the right

mid- clavicular line is 9 cm.

Genitourinary system

No costovertebral angle tenderness. Both testicles are descended. No suprapubic distension.

Integumentary System

The skin is warm but not dry. No rashes or ulcer. Normal hair distribution.

Locomotory System

There is no muscle tenderness or spasm. There is no bony deformity or tenderness. Grade 4 pedal, ankle
and pretibial edema.

Nervous system

Mental Status:

The patient is conscious, fully cooperative and doesn’t seem to be depressed. He is well oriented in time,
place and person. His speech is normal. He does not have any hallucinations or delusions. He has good
memory.

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Cranial Nerves:

N-I: Smells alcohol via each nostril.

N-II: normal visual acuity, good visual fields and color appreciation.

N-III, IV & VI: The eyes can move in all directions. There is no nystagmus or diplopia. The pupils are round,
regular in outline and equal in size. They react to light directly and consensually and accommodate
normally.

N-V: He identifies light touch and pin prick over the mandibular, maxillary and ophthalmic areas of the face.
He closes his eyes at the touch of the cornea with a cotton swab on both eyes. Contraction of the temporal
and masseter muscles is symmetrical and strong.

N-VII: The face is symmetrical at rest and during voluntary movements (smiling, raising the eye brows). He
can close both eyes equally and forcefully.

N-VIII: He hears the ticking of a watch bilaterally.

N-IX & X: The soft palate rises in the midline when saying ‘ah!’

N-XI: The Sternocleidomastoid and trapezius muscles contract on turning the head and on shrugging the
shoulder against resistance, respectively.

N-XII: The tongue protrudes in the midline and shows no fasciculation or atrophy.

Motor:

Muscle bulk: There is no muscle bulk reduction in all extremities and there is also no bulk difference
between the left and the right sides. There is no spontaneous as well as induced fasciculation.

 Muscle tone and power.

TONE POWER
Upper Lower Upper Lower
Right Normo-tonic Normo-tonic 5 5
Left Normo-tonic Normo-tonic 5 5

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Coordination:

Finger to nose, heal to shin and rapid alternating movement of the arm were done without any
abnormalities.

Pronator Drift test was negative.

Reflexes:

 Superficial reflexes: Plantar reflex is down going.

 Deep tendon reflexes:

Biceps Triceps Supinator Patellar Ankle

Right ++ ++ + ++ ++
Left ++ ++ + ++ ++

 Clonus: No clonus

Sensory: light touch, pain and temperature sensations are intact. Deep pressure, position sense, vibration
and passive movements are well appreciated by the patient. There is no ataxic gait or Romberg’s sign.
Normal recognition of form, size and shape of a coin as well as two point discrimination.

Meningeal Sign:

There is no neck stiffness.

Kernig's Sign is negative.
Brudzinski's Sign is negative.

Summary of problems
 Subjective summary:
o 40 year old known hypertensive(10 years) and diabetic patient(3 years)
o Generalized body swelling of 5 months and shortness of breath of 4 months durations
o Orthopnea and paroxysmal nocturnal dyspnea
o productive cough of 3 months durations
o history of flank pain, decreased urine output, urgency and frequency
o easy fatigability and change in sleeping pattern
o History of epistaxis, blurring of vision, headache and vertigo

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  Objective Summary:
o Decreased tactile fremitus, dullness percussion note and decreased air entry posteriorly
below scapula bilaterally
o Symmetrically distended abdomen with flanks full and positive signs of fluid collection
o Grade 4 pedal, ankle and pretibial edema

Differential Diagnosis
 Chronic kidney disease 2ndary to Diabetic nephropathy plus Hypertension
 Congestive heart failure 2ndary to Hypertension
 Nephrotic syndrome 2ndary to Diabetes
 Disseminated TB(lung, pleura and peritoneum)

Discussion of Differential Diagnosis

 Disseminated TB( lung, pleura and peritoneum) : TB can affect almost any organ in the body. It is
caused by Mycobacterium TB. Almost one third of the world population lives in TB endemic area. It
is one of the leading causes of mortality and morbidity. Most people are infected with TB but only
<10% develop the disease. The development of the disease is dependent on age,
immunosuppression, nutritional status and the index case. Disseminated TB is one that has origin in
the lung and then spread to other sites either hematogenously or via lymphatics.
In this patient who has history of contact with people who cough due to unknown
conditions, also lives in Maremia Bete( crowded places are risk factors for TB) plus the symptoms
like productive cough and edema which may be explained by involvement of the pleura and
peritoneum support the diagnosis. On the other hand no fever, sweating, no weight
loss(although this may be insignificant because of the edema) plus the patient is stable without
an-anti TB drugs up to now do not support the diagnosis. Investigations which should be done to
rule out TB include Chest x ray, AFB from sputum, pleural and peritoneal fluid analysis, sputum
culture, ESR and others.

 Nephrotic syndrome 2ndary to Diabetic nephropathy: nephrotic syndrome is a clinical complex

characterized by significant proteinuria(>3.5 g/1.73 m2 / 24 hr), hypoalbuminemia, edema,
hyperlipidemia and lipiduria. The causes are many among which diabetes is one. In children the
primary causes are common but in adults secondary causes are the dominant ones.
In this patient edema and associated conditions like dyspnea plus cough can be explained
by nephrotic syndrome. But the decreased urine output, flank pain, urgency, frequency is not the
features of NS. The investigations which should be done to rule out NS include 24 hrs urine

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 protein collection, urinary protein measurement by dipstick and in steroid non-responsive
conditions cases renal biopsy.

 CHF 2ndary to Hypertension: CHF is a clinical syndrome characterized by inadequate systemic

perfusion to meet the body’s metabolic demands as a result of abnormalities of cardiac structure
or function. The most common causes of heart failure is left ventricular dysfunction( in about 60-
70% of patients). Hypertension causes HF by increasing the afterload and then if not controlled lead
to left ventricular hypertrophy.
In this patient the signs of HF( SOB, orthopnea, PND) plus signs of pleural effusion and
edema which started from the legs are suggestive of CHF. But on Physical examination no
findings in cardiovascular system makes the diagnosis less likely. The investigations which should
be done to rule out CHF include chest X ray, ECG, Echo.
 Chronic kidney disease 2ndary to diabetic nephropathy plus Hypertension: CKD is the presence of
markers of kidney damage for 3 months, as defined by structural or functional abnormalities of the
kidney with or without decreased glomerular filtration rate (GFR), manifest by either pathological
abnormalities or other markers of kidney damage, including abnormalities in the composition of
blood or urine, or abnormalities in imaging tests. OR The presence of GFR <60mL/min/1.73 m2 for
3 months, with or without other signs of kidney damage as described above.
Among the most common causes are Diabetes mellitus and hypertension are the most
common causes. Other causes include interstial kidney diseases, drug induced and others. There are
stages of CKD from 0 to 5 based on GFR. Signs and symptoms include general(nausea, anorexia,
malaise), skin( Uremia frost, pruritus), neurologic( seizures, neuropathy, impaired sleep, restless leg
syndrome), cardiovascular( pericarditis, accelerated atherosclerosis, hypertension, hyperlipidemia,
volume overload, CHF, cardiomyopathy), hematologic( anemia, bleeding), metabolic(hyperkalemia,
hyperphosphatemia, acidosis, hypocalcemia)…

In this patient all the signs and symptoms can be explained by CKD plus the fact that
he is unresponsive to the treatment since 5 months back suggest he is towards end stage renal
disease. This patient is known diabetic and hypertensive which are among the leading causes in
causing CKD. Investigations suggestive of CKD include renal function tests(Cr and BUN plus GFR
by using the Cockgroft-Gault formula ), abdominal ultrasound( to look for shrinkage of the
kidneys) plus investigations for the cause.

Diagnostic Workup
 CBC with differential, ESR : to assess for presence of infection
 Chest X-ray : for cardiomegaly and rule out chest infections
 Urine analysis : to rule out UTI, nephrotic syndrome, nephritic syndrome
 ECG( hypertrophic and ischemic heart disease)
 Echo
 FBS
 Lipid profiles

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  Organ function tests( LFT and RFT)
 Serum electrolytes
 Abdominal ultrasound
 Thyroid function tests
 Fluid analysis(pleural and peritoneal)
 Renal biopsy

FINAL DIAGNOSTIC IMPRESSION

CHRONIC KIDNEY DISEASE 2NDARY TO DIABETIC NEPHROPATHY PLUS HYPERTENSION

PRINCIPLES OF MANAGEMENT

1) SUPPORTIVE TREATMENT: TO RELIEVE SYMPTOMS

2) DEFINATIVE MANAGEMENT: RENAL TRANSPLANT

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