A 67 year old female patient with CKD

 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. 

• Chief Complaint :-

A 67 years old female came to OPD with chief complaints of
-pedal edema since - 3months.
-Shortness of breath since - 3 months
- Decreased urine output since 3 months. 

• History of present illness :-

Patient was apparently asymptomatic 1yr back then she noticed decreased  urine output and was diagnosed to have  heart failure and renal  failure and started on conservative management. 
Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles . 
shortness of breath - grade 3 insidious onset and progressive.
No history of burning micturition, paroxysmal nocturnal dyspnoea,cough, cold, fever.

• History of past illness :-

K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.

• Medical history :-

For diabetes Tab Glimy 3mg/PO/BD.
For hypertension tab nicardia , Prolomet XL 50





• Personal history :-

 Diet - Mixed
 Appetite - Lost 
 Sleep - Adequate 
 Bowel and bladder movements- Irregular ( constipation) 
 Micturition - Abnormal
 No addictions.

• Family history:- 

No one of family has similar disease.

• General Examination :-

Patient is co-operative coherent consciousness and well oriented to place and time . 
No pallor, cyanosis, icterus, lymphadenopathy, clubbing of fingers.
Edema - present

• Vitals : -
 Temperature - 98 °F
 Bp - 160/100 mmHg
 Pulse rate - 100 bpm
Respiratory rate - 16 cycles/ min.

• Systemic Examination :-
  
Respiratory system -

Inspection : -

Chest is normal bilaterally symmetrical 
Position of trachea is central 
Movements are bilaterally symmetrical.
No scars , sinuses, or visible pulsations.
Suprasternal and supraclavicular notching is present.

Palpation :

No local rise of temperature
No tenderness
All inspectory findings are confirmed
Apex beat felt in 5th intercostal space 2cm lateral to midclavicular line .

Percussion :-

Resonant sound is heard
Auscultation 
Normal vesicular sounds are heard.

CVS -

Inspection :

Bilaterally symmetrical chest
No visible  engorged veins,scars or sinuses on chest.

Palpation :

S1 S2 are heard
No thrills , no murmurs 
Apex beat present at 5th intercostal space 2cm  lateral to midclavicular line .

Auscultation : 


No cardiac murmurs heard.

Abdomen - 

Obese, inverted umbilicus. 
No visible scars, sinuses, fistulas, engorged veins.
No organomegaly. 
Soft , non tender , no free fluid. 

CNS -

Conscious, speech is normal, no neck stiffness and kernings sign negative.
No finger and nose in coordination.

Provisional diagnosis: - Chronic renal failure 
HFpEF - Right heart failure.(Heart failure with preserved ejection fraction).

Investigations: - 

2D echo -





USG ABDOMEN :-






Complete Urine examination:-



Random Blood Sugar :-


Serum creatinine -


Serum electrolytes -


ECG -




Complete blood picture -







Management:- Hemodialysis

Tab Nodosis 500mg PO/BD
Tab shelcal PO/OD
Tab orofer XT PO/BD
Cap Bio D3 OD
Tab Nicardia 20mg PO/BD
Inj Erythropoietin 4000IU Once weekly





Comments

Post a Comment

Popular posts from this blog

50 year old female with fever, vomiting, burning micturition,SOB

Image
A 50yrs old female c/o fever, vomiting, burning micturition,SOB 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 box. Chief Complaints: C/O Fever since 10days, Burning micturition since 10days, vomitings since 10days (5-6 episodes),Grade 3 SOB since 10days History of Present Illness: Patient is apparently asymptomatic 10days back then she noticed fever low grade,continuous type not associated with chills and rigors H/o vomiting non projectile,non bilious,food as content C/o SOB Grade 3 since 3days C/o burning micturition after foleys i
Read more

A 70year old male patient came to the OPD with the cheif complaint of increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs

Image
  A 70year old male patient came to the OPD with the cheif complaint of increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs  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 box. A 70year old male patient came to the OPD with the cheif complaint of increase in blood pressure, decrease in urine output since 15days, involuntary movements of B/L limbs since 12pm on 20/11/2022. • cheif complaint:- increase in blood pressure, decrease in urine output since 15days, involuntary movements of B
Read more