1801006055 SHORT CASE

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.

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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 52 year female came with chief complaints of bilateral pedal edema and shortness of breath since 5 months.

HOPI

Patient was apparently asymptomatic 5 months back then she developed bilateral pedal edema, shortness of breath, and decreased urine output associated with facial puffiness and went to a hospital for which she was investigated and diagnosed as chronic renal failure and was treated with medicines, patient was non complaint.

Then 4 months back she developed SOB of grade 4 along with excessive sweating and was brought to our hospital where she was advised to undergo dialysis.

Since then she had almost 19 cycles of dialysis.

First hemodialysis on 19/5/22

Last hemodialysis on 04/8/22 

She is found to be anaemic with hemoglobin levels of about 3.5gm/dL for which transfusion was done.

Past history

H/o hypertension since 10 years

No H/o Diabetes mellitus, CAD, asthma, epilepsy, tuberculosis. History of blood transfusion.

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.

Pallor is present.

Bilateral pedal edema till the level of below the knees is present.

No features indicating the presence of 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. 

PROVISIONAL DIAGNOSIS

Chronic kidney disease.

Hypertension since 10 years

Investigations

Hemogram

Hb 3.4 

Total count 13100

Lymphocytes 16

Renal function test

Urea 54mg/dl

Creatinine 4.4 mg/dl

Phosphorus 2.2mg/dl

Sodium 135mEq/l

Pottasium 3.2mEq/l

Treatment 

Salt and fluid restriction.

Inj.Erythropoietin 4000IU weekly twice.

Tab.Nodosis 500mg PO/TID

Tab.Shelcal 500mg PO/OD

Cap.Bio D3 PO/weekly once

Tab. Lasix 40mg PO/BD

Monitor vitals

Tab.Nicardia 10mg PO/OD