48/F C/o - CKD

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.

This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation

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 A 48 year old female working as a daily wage labourer hailing from buttuguda presented to the opd with c/o

swelling in lower limbs since 10 days
shortness of breath since 7 days
she also complained of 2 episodes of vomiting since 2 days along with 4 episodes of loose stools since 2 days

HOPI
The patient was apparently asymptomatic 2 months ago , when she had a high fever , progessive swelling of her lower limbs and shortness of breath on exertion . She went to an RMP 2 montha ago and she was incidentally found too have anaemia due to CKD , for which she was transfused with 2 unit of blood , after which she reported 3 episodes of vomiting and 4 episodes of loose stools , the referred her to KIMS narketpally

Past illness
-Hypertension since 2 years , not on regular medication 
-cataract surgery in right left eye 1 year ago

family history
not relevent
personal history
diet : mixed
appetite : loss of appetite
micturition : reports nocturia (2-3 times every night)
bowel movements : normal
addictions : smoked biddi since 35 years , stopped due to recent illness
allergies : not known

General examination
patient was c/c/c
pallor : present 
icterus : absent
cyanosis : absent
clubbing : absent
lymphadenopathy : absent
pedal edema : bilateral pedal edema , pitting type




vitals
pulse rate : 106 bpm
BP : 130/70
RR : 20 cpm
temperature : 100 F
 
INVESTIGATIONS 

creatinine levels 




  
provisional diagnosis :- CKD
                                        - anaemia of chronic inflammation
treatment 

1. TAB. LASIX 40 MG 1 TAB TWICE DAILY AFTER FOOD AT 8 AM- 4 PM.
2. TAB. NODOSIS 500 MG 1 TAB TWICE DAILY AFTER FOOD AT 8 AM - 8 PM.
3. TAB. PAN 40 MG 1 TAB ONCE DAILY BEFORE FOOD AT 7 AM.
4. TAB. OROFER XT 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
5. TAB. MVT 1 TAB ONCE DAILY AFTER FOOD AT 2 PM.
- 6. CAP. BIO D3 1 TAB ONCE WEELY AFTER FOOD AT 2 PM.
7. FLUID RESTRICTION LESS THAN 2 LITERS/DAY.
8. SALT RESTRICTION LESS THAN 2 GRAMS/DAY.

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