1801006104-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.    



March17,2023


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  

https://drive.google.com/uc?export=view&id=1anjNTDirOX3l2Z9bktL5bR9P3Zkn3U3Shttps://drive.google.com/uc?export=view&id=1J5nmBuX-0b9Y5hSXqZEcSrudaAteoxGf


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(13-17)

TLC - 5000cells /mm3(4000-10000)

Platelets - 2 lakhs /mm3(1.5-4.1)

Normocytic normochromic anemia 

RFT:

Urea - 113 mg/dl (12-42)

Creatinine- 7.4mg/dl(0.9-1.3)


LFT:

Total bilirubin - 0.8mg/dl(0-1)

Direct bilirubin - 0.1mg/dl(0-0.2)

AST- 19 IU/L(0-35)

ALT- 12 IU /L(0-45)

ALP- 82IU/L(53-128)

Albumin - 4gm/dl(3.5-5.2)

Protein - 7gm/dl(6.4-8.3)


ABG:

pH - 7.3 (7.3-7.45)

Pco2 - 31 (35-45)

Po2 - 92 (85-95)

Spo2 - 97% 

HCO3 - 18


Xray :
https://drive.google.com/uc?export=view&id=1fM4hRKAqi8K3XLHNvs0IpP8Vn-BFppow

USG:

Kidney shrunken , grade 2-3 rpd


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 

Comments

Post a Comment

Popular posts from this blog

1801006104-LONG CASE

Image
March18,2023 79 Y/O MALE WITH RECURRENT CVA AND LEFT HEMIPLEGIA WITH ASPIRATION PNEUMONIA AND SEIZURES DISORDER CHEIF COMPLAINTS :- A 79 year old male was brought to the OPD with cheif complaints of cough since 20 days ,C/o altered sensorium since 3 days, difficulty in swallowing since 1 month and fever since 10 days HOPI :- Patient was apparently asymptomatic 20days back then  he developed cough which was insidious in onset and gradually progressive. The cough was productive but patient was not able to spit it out and he also faced Difficulty in swallowing. 20 days back ( on feb 25th) he started to have cough and cold On march 1st took treatment for cold On march 3rd secretions got increased and he was unable to spit that out After 2 days went to a hospital and got admitted for 5 days during which he got those secretions cleared out H/o change of voice since 20 days, insidious, hoarse in character and  Slurring of speech was seen. H/o cough on intake of liquids. No h/o hemoptysis, dif
Read more

58 yr old woman with fever and thrombocytopenia

Image
Vamshi krishna   Roll no :99 CHEIF COMPLAINTS :   A 58 yr old woman farmer by occupation resident of nakrekal presented to op with chief complaints of fever and swelling on both legs. HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 5 days back. Then she developed fever which was insidious in onset intermittent in nature and relieved on medication(dolo) and increases during night time around 4 AM. 5 days before the onset of fever she was travelling to nearby villages in rains and had decreased appetite and has also been working on her farms.  There is history of swelling in the foot which was gradual and associated with onset of fever and has decreased since 2 days.  There is a history of loose stools  5 days back with 4 episodes which was because of intake of Vamu ( Ajwain) , ( which she normally takes due to her constipation i.e., she has bowel movements once every 3 days and every time before she had normal motions but this time it was diarrhea) and associated with
Read more

19 year old male with fever and lower back pain

Image
December 02,2022 19 Year old male with fever and lower backache December 01,2022  This is an 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. 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 This is a case of 19 year old male from mirylaguda who is intermediate second year student came to general medicine OPD with  chi
Read more