30 year old female patient with chronic kidney disease on maintenance on hemodialysis
Long case final practical-1701006067
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 comments on comment box is welcome.
MEDICINE CASE DISCUSSION:
I've 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 a diagnosis and treatment plan.
VIEW OF THE CASE :
30 years old female, who is HOUSEWIFE by occupation resident of nalgonda
came to the opd with the CHEIF COMPLAINT of
Abdominal pain since 7 days
shortness of breathe since 4 days
pedal edema since 4 days
facial puffiness since 4 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 12 months back
then she developed
Abdominal pain : pain since 7 days which started suddenly and burning type of pain In epigastric region No aggravating and reliving factors
Breathlessness:
shortness of breathe since 4 days which is of grade 4 and associated with profuse sweating.
SOB: insidious in onset gradually progressed to grade 4 not associated with change in position no aggravating and relieving factors
Abdominal pain : pain since 7 days which started suddenly and burning type of pain
In epigastric region
No aggravating and reliving factors
PEDAL EDEMA:
She complaints of pedal edema since 4 days which is of pitting type. She had similar edema episodes before this one month which were resolving and reappearing and this time it is not resolved for 1 month.
She also developed facial puffiness
No history of FATIGUE
no history of COUGH, HAEMOPTYSIS
No history of DYSPHAGIA, HOARSENESS OF VOICE
No history of HIGH ARCHED PALATE, CHEST DEFORMITY
No history of RECURRENT RESPIRATORY TRACT INFECTIONS, FEVER, SORE THROAT, CLUBBING, SPLINTER HAEMORRHAGE
No history of FEVER, JOINT PAINS
PAST HISTORY:
She is diagnosed as Gestational HYPERTENSION 12 years back for first pregnancy (after 4th child she discontinued use of anti hypertensive drugs)
She is a not a known case of diabetes, asthma, epilepsy, hyperthyroidism, COPD
No history of blood transfusion
no history of allergy
MARTIAL HISTORY:
Age of menarche 12 year
Marital History:
Age of marriage 18 years
It is a nonconsanguinous marriage
She has 4 children
( in 2011 first child(girl )- normal vaginal delivery -diagnosed as HYPERTENSION
In 2012 second child(girl)- normal vaginal delivery
In 2014 third child(girl) - normal vaginal delivery
In 2015 fourth child(girl)- normal vaginal delivery -she also had episode of Dyspnea of grade 3 (not get attention to symptoms)
FAMILY HISTORY:
father and mother are known case of HYPERTENSION since 6years
PERSONAL HISTORY:
DEIT: mixed
APPETITE: loss of appetite
BOWEL :normal
BLADDER: DECREASED URINE OUTPUT
SLEEP: INadequate
ADDICTIONS: no addictions
GENERAL EXAMINATION:
A 30 year old patient, who is moderately built and well nourished is CONSCIOUS, COHERENT, COOPERATIVE, AND COMFORTABLY LYING ON BED, well oriented to TIME, PLACE AND PERSON.
THERE IS PALLOR
NO icterus
NO cyanosis
No koilonychias
No generalized lymphadenopathy and
No pedal edema
Vitals:
Temperature: a febrile
Pulse: 92/ min
Blood pressure: 150/90 mmHg
Respiratory rate : 34 cpm
SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM
Patient examined in sitting position
INSPECTION
oral cavity- Normal ,nose- normal ,pharynx-normal
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position & Nipples are in 4th Intercoastal space
APEX IMPULSE VISIBLE IN 6TH INTERCOASTAL SPACE
PALPATION
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 6 thICS,
Chest movements bilaterally symmetrical reduced
Tactile and vocal fremitus REDUCED on both sides in infra axillary and infra scapular region
PERCUSSION
DULL IN BOTH SIDES in infra axillary and infra scapular region
AUSCULTATION
DECREASED ON BOTH SIDE in infra axillary and infra scapular region
BRONCHIAL sounds are heared -REDUCED
CARDIOVASCULAR SYSTEM
JVP -raised
Visible pulsations: absent
Apical impulse : shifted downward and laterally 6th intercostal space
Thrills -absent
S1, S2 - heart sounds MUFFLED
PERICARDIAL RUB-PRESENT
ABDOMEN EXAMINATION:
INSPECTION
Shape : distended
Umbilicus:normal
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal
PALPATION
Liver is not palpable
PERCUSSION- dull
AUSCULTATION :bowel sounds heard
Investigations
HIV TEST
DIAGNOSIS:
IT IS A CASE OF CHRONIC KIDNEY DISEASE ON MAINTENANCE OF HEMODIALYSIS
TREATMENT
INJ. MONOCEF 1gm/IV/BD
INJ. METROGYL 100ml/IV/TID
INJ PAN 40mg/IV/OD
INJ. ZOFER 4mg/iv/SOS
TAB. LASIX 40mg/PO/BD
TAB. NICORANDIL 20mg/PO/TID
INJ. BUSOCOPAN /iv/stat
Add on
TAB. OROFER PO/BD
TAB. NODOSIS 500mg/PO/TID
INJ.EPO 4000 ml/ weekly
TAB. SHELLCAL/PO/BD
DIALYSIS (HD)
INJ.KCL 2AMP IN 500 ml NS over 5min
Comments
Post a Comment