General medicine elog 4 (Nephrology)





Anahita behara 

roll no 08

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


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 a diagnosis and treatment plan

ongoing case 

A 60 year old female had come to the OPD with complaints of swelling in legs since one month and shortness of breath and one week .

Chief complaint

Shortness of breath : one week 

Pedal Edema : one month 

Is a known case of CKD (chronic kidney disease) on MHD () since 2 months secondary to analgesic nephropathy 

Last dialysis on 8th May 2021

Known case of hypertension (since one year)

Not a known case of DM , thyroid , tuberculosis 


HISTORY OF PRESENT ILLNESS 

-Patient was apparently asymptomatic one year ago and then developed pedal edema and went to the nearest hospital where she was diagnosed with hypertension and was treated.

HISTORY OF PAST ILLNESS 

-Two months back the patient developed pedal edema and shortness of breath for which she visited the nearest hospital for which they were advised to visit KIMS .

Later on Dialysis was started as per requirement

-Her left eye was operated on 20 years ago as it had become septic after an agricultural accident she was prescribed tablets (unknown) that she took for 15 years , and stated that her kidney disease was caused due to those tablets  

TREATMENT HISTORY 

Treated for hypertension (since one year)

-Clinidipine 10mg (daily , after breakfast) 

PERSONAL HISTORY 

-occupation : previously an agricultural worker (20 Years ago)  and now a housewife 

-diet : mixed 

-bladder : normal 

-bowel : regular 

- no known addictions 

FAMILY HISTORY 

Irrelevant 

MENSTRUAL HISTORY 

Age of menarche : 13

Reached menopause : 10 years ago

GENERAL EXAMINATION 

Pallor : not present 

Icterus : not present 

Cyanosis : not present 

Clubbing : not present 

Lymphadenopathy : not present 

Pedal edema : not present 

Temperature : 98.6 degree Celsius 

Pulse rate : 88 bpm

Respiratory rate : 16 cpm

Blood pressure : 140/90 mmHg

SPO2 at room air : 98 % 

SYSTEMIC EXAMINATION 

CVS 

Thrills : not heard 

Cardiac  sounds : S1,S2 heard 

Cardiac murmurs : not heard 

RESPIRATORY SYSTEM 

Dyspnoea : present 

Wheeze : is present 

Position of trachea : central 

Breath sounds : vesicular 

ABDOMEN EXAMINATION

-Shape of abdomen : scaphoid 

PROVISIONAL DIAGNOSIS 

CKD (Chronic kidney disease)

DIAGNOSTIC IMAGING 

<ultrasound report>


 <pre-operative Doppler ultrasonographic  >





HEMODIALYSIS CHART 





Urine examination 



Blood reports 

















TREATMENT PLAN 

1. Tablet nicardia 10mg PO/BD 

2.Tablet Nodosis 500mg PO/OD

3.Tablet Orofer XT PO/BD

4.Tablet Shelcal PO/OD

5. Injection Erythropoetin 4000IU (Sub cutaneously weekly twice )

6.BP monitoring fourth hourly 



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