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 patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient- centered online learning portfolio and your valuable inputs on the comment.


A 50 year old female came to OPD with chief complaints of shortness of breath and bipedal edema.

HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 3years back, then she complaints of headache to which she was diagnosed as hypertension. She is a   known case of hypertension since then.

8months back, patient complaints of shortness of breath which is aggravated in supine position and she complaints of pedal edema which is pitting in nature and decrease urine output to which she was admitted to KIMS. She was diagnosed as chronic kidney disease. She was on maintenance haemodialysis since then.
 She was undergoing two sessions of dialysis in one week.

Since one month, patient complains of fever which is high grade intermittent which subsides on medication and cough which is copious and non blood tinged.

Yesterday, she complaints of vomiting which is projectile , 3 -4 episodes in a day after a session of dialysis.

PAST HISTORY:

 She is a known case of hypertension since 3years and chronic kidney disease since 8months.

She is not a known case of Diabetes, asthma , COPD and tuberculosis.

PERSONAL HISTORY

Diet -mixed
Appetite- normal
Bowel and bladder habits- constipation
Sleep - adequate

FAMILY HISTORY:

 There is no history of similar complaints in the family.

TREATMENT HISTORY:

  Patient is not allergic to any known drug.

GENERAL EXAMINATION

patient was conscious,coherent, cooperative and well oriented to time, place and person.

Pallor is seen.
No icterus
No cyanosis
No history of generalised lympadenopathy 

Bipedal edema is seen.




 







VITALS:

Temperature: afebrile
Respiratory rate: 18cpm
Pulse rate: 70bpm
Blood pressure: 130/90mm Hg
GRBS: 290
Spo2 at room temperature:99%



SYSTEMIC EXAMINATION:

Cvs examination: 

Inspection : 

No precordial bulge

No scars sinuses and engorged veins

No visible pulsation

Palpation:

apical impulse : heard in fifth inter coastal space

Auscultation:

S1 and S2 heard

No murmurs.

CNS examination:

Higher mental functions-normal 

Cranial nerves- intact
Sensory system- normal

Motor system- normal 
Meningeal signs- absent 

Cerebellar signs- absent
Respiratory system examination:


Inspection of upper respiratory system- 


oral cavity- normal


Nose- normal 


Pharynx- normal 


Lower Respiratory Tract:


Inspection: 


trachea: central 


Symmetry of chest : symmetrical 


Movement: B/L symmetrical expansion of chest respiration


No scars, engorged veins or sinuses.


Palpation:


All inspectory findings are confirmed by palpation.


Trachea: central - confirmed by three finger test.


Assessment of anterior and posterior chest expansion- B/L symmetrical expansion of chest.


No chest wall tenderness 


Vocal fremitus- normall


Percussion : 


done in sitting position 


Resonant


Auscultation: 


Vesicular breath sounds heard


Bilateral air entry present


No added sounds


*Abdominal examination:


Inspection:


Shape : elliptical 


Quadrants of abdomen moving in accordance with respiration.


No scars sinuses or engorged veins 


Palpation:


No tenderness 


No organomegaly


Percussion:


tympanic 


Auscultation:


Normal 


 PROVISIONAL DIAGNOSIS: 

CHRONIC KIDNEY DISEASE 

INVESTIGATION:












FINAL DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH MHD.

TREATMENT:

9th January 

Tab NODOSIS 500mg BD

Tab NICARDIA 10mg BD 

Tab LASIX 40mg BD

Tab ARCAMINE 0.1mg TID

Tab SHELCAL 500mg BD

Tab OROFERXT OD

Tab PAN 40mg OD

Inj Erythropoietin 4000 IV/SC weekly once

Inj IRON SUCROSE 1AMP in 100ml NS during dialysis

FLUID RESTRICTION<1l per day

SALT RESTRICTION<2.4g/day












 

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