A 18 year old with chronic kidney disease
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4/8/22
6/8/22
Treatment
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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.This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
Maheshwari Jagathkari
Roll no 57
Case report
A 18 year old female presented with chief complaints of
Shortness of breath since 3 days i.e., 2/8/22 2:00PM
Pain abdomen along with 2 episodes of vomiting.
Decreased hearing in right ear since 4 years.
HOPI
Patient was apparently asymptomatic 3 months back.
Then she developed shortness of breath which was of Grade 4 and pedal edema upto the level below the knees which was pitting type and also facial puffiness.
She also had fever and few episodes of vomiting for which she was taken to a hospital and evaluated accordingly and was said to have some infection for which she was put on medication.
3 days back she developed shortness of breath which of grade 4 and was brought to our hospital.
She had pain in the right hypochondriac region which was dull aching type non radiating associated with 2 episodes of vomiting which was non projectile, food as contents.
Patient also complaints decreased hearing in right ear since 4 years associated with ringing sensation.
History of trauma to right ear 4 years back.
No history suggestive of any ENT complications.
Daily routine
Patient wakes up at around 6 AM then gets freshned up does some household chores drinks her tea at around 8 AM, breakfast at 9 AM washes utensils and other works then has her lunch at 2 PM then watches TV for sometime spends time with her cousins and sleeps for sometime dinner at 9 PM and sleeps at around 10 30 PM.
Past history
No H/o Diabetes mellitus, Hypertension, CAD, asthma, epilepsy, tuberculosis. History of blood transfusion is present 3/8/22.
Personal history
Diet is mixed with normal appetite and regular bladder movements, sleep is adequate.
No addictions.
No drug allergies.
General examination
Patient is conscious, coherent and cooperative, well oriented to time, place and person, poorly built and nourished.
Pallor is present.
No features indicating the presence of pedal edema, icterus, cyanosis, clubbing, lymphadenopathy.
Vitals
Pulse rate 90bpm
Blood pressure 130/80mmhg
Respiratory rate 18cpm
Temperature - Afebrile
Systemic examination
CVS- S1 and S2 heart sounds heard, no murmurs.
RS- Bilateral air entry is present, normal vesicular breath sounds heard.
ABDOMINAL EXAMINATION
INSPECTION
No distention
No scars
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
PALPATION
No local rise of temperature
Abdomen is soft with no tenderness.
No spleenomegaly, hepatomegaly.
PERCUSSION
Liver span is 12cm.
No hepatomegaly
Fluid thrill and shifting dullness absent.
No puddle sign.
AUSCULTATION
Bowel sounds present.
No bruit or venous hum.
CNS examination
Higher motor functions intact
No focal neurological deficits noted.
ENT examination
Patient complaints of decreased hearing in right ear since 4 years more to soft sound, non fluctuant no aggravating and relieving factors.
History of ringing sensation in rt ear since 4 years which is intermittent.
History of ear pain, insidiou, intermittent, pricking type aggravated on chewing and relieved on taking medication.
No H/O giddiness, nausea, vomiting, fever.
No H/O nasal obstruction, nasal discharge.
RT sensorineural hearing loss.
Ophthalmic examination
Provisional diagnosis
Chronic kidney disease
Alport syndrome?
Right sensorineural hearing loss.
Investigations
3/8/22
Pure tone audiometry
Fluid and salt restriction
Inj.Erythropoietin 4000IU weekly twice
T.Nodosis 500 mg PO/BD
T.Shelcal 500mg PO/OD
T.Orofer-XT PO/OD
Cap.Bio D3 PO weekly once
Inj.Lasix 20 mg IV/BD (If SBP greater than 110mmHg)
BP monitoring 4th hrly
Inj.Cefrdaxone 500mg IV/BD
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