Case Presentation

NCD
Group 2
Skand Rastogi
Gaurika Jain
Khushi Trivedi
Nandana S
Eesha Panghal
Fiza Firoz
Sakshi Bali
Vani Mittal
Aditya Kejriwal
Sanyaktha Kamath
General Information
● Name: Mr. Mohan
● Age: 35 years old
● Gender: Male
● Address: 1-247 Neralakatte House, Bantwala Taluk, Dakshina Kannada,
Mangalore
● Religion: Hindu
● Literacy Status: 10th class
● Occupation: Dance Teacher
● Date of Admission: 20th January 2022
● Ward: 2C
● Total Family Income: 15,000
● Socioeconomic Status: Lower Middle Class
Chief Complaints

● Bilateral Leg Swelling x 5 months

● Facial Swelling x 1 month
History of Presenting illness
● The patient, a known case of Diabetes and Hypertension for the past 7 years and 5
years respectively, comes with the complaint of facial swelling for the past 1 month.
● The swelling was insidious in onset and progressive in nature.
● The swelling involved the complete right side of the face and the left eyelid.
● The swelling used to increase in the morning and night and reduces during the day.
● The patient also complains of bilateral leg swelling for the past 5 months which was
insidious in onset, progressive in nature and involved the whole leg from the knee to
the toes.
● The right leg swelling started one month after the left leg swelling.
● The swelling was present throughout the day.
● The left leg swelling was accompanied by pain which was insidious in onset, sharp
in character, on & off in nature and did not radiate.
● The pain was aggravated by walking and consumption of alcohol and relieved on
taking rest.
● The patient also complains of increased urine output as he has to wake up 2-3 times
during the night to go to the washroom.
Negative History
● No h/o chest pain, breathlessness
● No h/o exposure to allergens
● No h/o blurring of vision
● No h/o tingling or numbness
● No h/o fever, headache
● No h/o cough and expectoration
● No h/o TB infection
● No h/o jaundice
● No h/o burning micturition
● No h/o trauma
 Past History
● The patient is known case of hypertension since 5 years and diabetes
since 7 years and is currently taking medication for both.
● The diagnosis of diabetes was incidental when he went to the hospital with
the complaint of hemoptysis after consuming alcohol 7 years ago.
The patient was shifted from oral medication to insulin 5 years back since
blood sugar was not under control with oral medication
● The diagnosis of hypertension was done in a routine check up 5 years ago
and the patient is taking medication (telmisartan)
● The patient says he was not compliant with his medications and rarely
went for routine check ups; about once in 3 years.
● Patient does not give history of asthma, stroke, thyroid
disorders,tuberculosis, mumps, rubella and previous surgeries.
Personal History
● The patient consumes a mixed diet with reduced appetite, disturbed sleep as
he has to wake up 2 to 3 times during the night to go to the washroom due to
increased urge for urination.
● He has normal bowel habits
● The patient used to consume alcohol every day; whiskey 180 ml.
● He started drinking from the age of 20 years and was asked to stop drinking
because of diabetes 7 years ago but didn’t.
● He recently stopped drinking five months ago when he observed leg swelling
● No history of smoking
● He used to chew tobacco till 5 months back; 11 packets/day.
● He used to spend about 2500 per month on alcohol and tobacco.
Family History
● The patient’s mother is hypertensive and has diabetes
● No habits and morbidities in siblings
Treatment History
● The patient is currently on insulin therapy and medication for hypertension
from the past 5 years.
● The patient is undergoing dialysis 3 times per week started from 21st January
2022.
Diet History
Family and Social History
● Type of family : Joint family
● Total number of family members : 10
● Total family income - Rs 15000/Month
● Relation with neighbours and relatives - Good
● According to Modified Kuppuswamy scale :
○ Education of head : 9th grade - 3
○ Occupation: Market Sale Worker - 6
○ Family monthly income: Rs 15000 - 2

= 11 (Lower middle class)

 Family Table

S.no Name Age Gender Relation Education Occupation Health Income Habits
to head

1. Jayanta 48 M Head 9th Jewelry shop - -

15000

2. Ramachan 71 M Father - - - - -
dran

3. Indira 60 F Mother - Housewife Diabetes - -

and HTN

4. Hemawati 46 F Sister 7th - - - -

5. Gayatri 44 F Sister 10th - - - -

6. Sarojini 42 F Sister 10th - - - -

7. Jayashri 40 F Wife - - - - -

8. Mohan 35 M Brother 10th Dance Diabetes - Alcohol

instructor and HTN Tobacco
chewing

9. Joshita 11 F Daughter - - - - -

10. Joshanita 7 F Daughter - - - - -

Family chart
Housing and Environment
● Type of House - Pacca
● No. of Rooms - 6
● No. of Bathrooms - 1
● No. of Kitchen - 1
● Source of water supply - Supply line
● Cross Ventilation - Present
● Cooking fuel - Gas cylinder
● Connectivity - Connected to a nearby PHC within 2 kms
● Sanitation - Waste collection by Municipality
● Source of water - Common society tap
General Physical Examination
Patient is conscious, co-operative and well oriented to time, place and person.
WEIGHT - 54kg Pallor - Present
HEIGHT - 173cm Icterus - Present
BMI - 18 kg/m2 Cyanosis - Absent
Respiratory Rate - 20 breaths/min Clubbing - Absent
Pulse - 90 bpm Edema - Present,Pitting type,
BP - 170/100 mmHg (grade 2 hypertension ) Bilaterally
Systemic Examination
Peripheral Nervous System Examination
Inspection
● Both the legs are swollen
● Wasting of muscles of left leg is seen
● The skin appears dry and the nails are brittle
● No scars or sinuses seen
Palpation
Could not be done as the patient wasn’t compliant.
Systemic Examination
Gastrointestinal system - Soft, non tender, no organomegaly

Respiratory system - Normal vesicular breath sounds heard , no added sounds

Cardiovascular system - S1 and S2 heard, no murmurs

Central nervous system - No focal neurological deficit.

Summary
A 35-yr old male from lower middle class (according to modified kuppuswamy
scale ) came to the Government Wenlock Hospital on 20th January 2022 with
chief complaints of bilateral leg swelling for the past 5 months and facial swelling
for 1 month. The left leg swelling was accompanied by pain which used to
increase on walking and consumption of alcohol and decrease on taking rest. He
is a known case of diabetes since 7 years and hypertension since 5 years and is
not compliant with his medications.
REPORTS AVAILABLE
INVESTIGATION 20th Jan 4th Feb 15th Feb 2022 NORMAL VALUES
2022 2022

Hb 12.8 g/dl 12.5g/dl 13.1g/dl 14-18 g/dl

TLC 7200 18600 22400 4000-11000 per cumm

ESR 9mm/hr - - 0-22mm/hr

Platelets 2 lakhs per 1.3 lakhs 1.13 lakhs 1.5-4.5 lakhs per microliter
microliter

RBS 245 196 mg/dl 210 mg/dl Below 200 mg/dl

UREA 150 43 mg/ dl 97 mg/dl 6-24 mg/dl

CREATININE 12.42 3.33 6.84 mg/dl 0.7-1.3 mg/dl

INVESTIGATIONS 20th Jan 2022 4th Feb 2022 15th Feb 2022 Normal Values

Na+ 137 141 130 135-145 meq/L

K+ 4.62 3.03 4.15 3.6-5.2 meq/L

Cl- 95.1 90.9 92.3 96-106 meq/L

HCO3- 23.6 25.4 16.4 22-29 meq/L

Total bilirubin 0.15 - - Upto 1.2 mg/dl

Direct bilirubin 0.03 - - Upto 0.03 mg/dl

AST 11 - - 5-40 U/L

ALT 16 - - 7-56U/L

ALP 236 - - 44-147 mg/dl

Total Protein 6.2 - - 0-14 mg/dl

HbA1c 6.4 - - 4-5.6%

REPORTS AVAILABLE
Urine Examination on 21 January 2022

● Glucose - ++
● Protein - ++
● Blood - +++
● Pus cells - 149/hpf (0-5/hpf)
● RBCs - 61/hpf (less than 2/hpf)
Diagnosis
Insulin Dependent Diabetes Mellitus and Hypertension with findings of Chronic
Kidney Disease.
 Knowledge, Attitude and Practice
Particulars Knowledge Attitude Practice

Diagnosis and treatment of CKD aware Positive Taking treatment

Administration of insulin and risk of Aware Positive Takes treatment but

hypoglycemia irregular

Danger signs of complications of DM unaware Willing to know _

and hypertension

Prevention of other complications of unaware Willing to know _

DM and hypertension

Dietary modifications to be made aware Negative _

Importance of exercise Unaware Willing to know _

Need for regular monitoring Aware Negative _

 Web of Causation Poor health
seeking behaviour

Malnutrition Lifestyle Poor

Key:
Education
Maternal Red- Causes
Diabetes diabetes
Pink- Causes chronic
Decreased
kidney disease
Decreased
awareness Blue- Causes
dietary fibre Diabetes hypertension
intake

Chronic
kidney
Alcohol disease

Poor Hypertension
nutrition Decreased
socioeconomic
status
Levels of Prevention Failed

● Primary and Secondary Prevention failed as the patient is in the

hospital and has developed complications.
● Tertiary Prevention is going on as he is undergoing treatment
for his complications.
Measures suggested to improve health status

a) Individual Level
If the patient gets discharged, we will tell him the importance of regular blood
glucose and blood pressure monitoring and being regular with taking his
medications.
Also, we will advise him to eat food with low glycemic index and reduce protein and
salt intake.
b) Family Level
We will ask all the family members aged above 30 to get screened for diabetes and
hypertension; and ask them to encourage patient to come for follow up visits
c) Community Level
National Programme for Prevention and Control of Cancer, Diabetes,
Cardiovascular Diseases and Stroke (NPCDCS).
THANK YOU