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