1801006112 - short case
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 60 year old female resident of Nalgonda , housewife came to OPD with chief complaints of bilateral leg swellings since 3 months , facial puffiness since 3 months , decreased urine output since 1 week
History of presenting illness :
Patient was apparently asymptomatic 3 months back then she developed bilateral pedel edema insidious in onset , gradually progressive ,pitting type , not associated with joint pain, no aggravating and relieving factors.
She developed facial puffines since 3 months
She developed decrease in urine output since 1 week , 1-2 times a day
She had no history of fever , burning micturation
No history of dyspnea, orthopnea, fatigue, chest pain
No history of abdominal pain , vomiting
Past history :
Known history of hypertension since since 2 months
History of NSAIDS intake since 4 years for body pains
Not a known case of diabetes , tuberculosis, asthma, epilepsy
There is a history of brain surgery 5 years ago due to fall
Personal history:
Diet - mixed
Sleep - decreased
Appetite- decreased
Bowel - normal
Bladder - decreased urine output since 1 week
Family history:
Not significant
General examination:
Patient is conscious,coherent,cooperative well oriented with time ,place and person
She is moderately built and moderately nourished
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
No lymphadenopathy
Edema - pitting type
Vitals :
Temperature- 98.2
Pulse rate - 80bpm
Respiratory rate - 16 cpm
Blood pressure- 120/70mmhg
Spo2 : 98%
GRBS : 120mg/d
Systemic examination:
PER ABDOMEN
On Inspection
- Umbilicus is central and inverted
- All quadrants are moving with respiration symmetrically
- No visible scars , sinuses , engorged veins and pulsations
- No hernial orifices
- External genitilia normal
On Palpation
- No local rise of temperature and tenderness
- Abdomen is soft and non tender
- No organomegaly
On Percussion
- Tympanic note heard over the abdomen
On Auscultation
-Bowel sounds are heard
-No bruit
CVS :
Inspection-
Chest is barrel shape , symmetrical , no dilated veins , scars and sinuses seen
Palpation -
Apical impulse felt at 5th inter coastal space
Auscultation- S1 , S2 heard , no murmurs
RESPIRATORY SYSTEM:
Inspection-
Chest is symmetrical, trachea is central
Palpation -
Trachea is central ,
Bilateral chest movements equal ,
Percussion - resonant
Auscultation-
Normal vesicular breath sounds heard
CENTRAL NERVOUS SYSTEM:
Higher mental functions - normal memory intact
cranial nerves :Normal
sensory examination:
Normal sensations felt in all dermatomes
motor examination-
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
reflexes-
Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
cerebellar function-
Normal function
Provisional diagnosis - kidney disease
Investigations:
Hemogram :
HB - 8.1 gm/dl
TLC - 5000cells /mm3
Platelets - 2 lakhs /mm3
Normocytic normochromic anemia
RFT:
Urea - 113 mg/dl
Creatinine- 7.4mg/dl
LFT:
Total bilirubin - 0.8mg/dl
Direct bilirubin - 0.1mg/dl
AST- 19 IU/L
ALT- 12 IU /L
ALP- 82IU/L
Albumin - 4gm/dl
Protein - 7gm/dl
ABG:
pH - 7.3
Pco2 - 31
Po2 - 92
Spo2 - 97%
HCO3 - 18
Xray :
USG :
Kidney shrunken
Final diagnosis - chronic renal failure
Treatment:
1. Fluid restriction
2. Salt restriction
3. LASIX 40mg PO/BD
4. NICARDIA 10mg PO/BD
5. Inj.EPO 4000 IU SC once weekly
6. Dialysis 3 times
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