60 Year Old Female with CKD on Maintenance Haemodialysis......
December 05, 2023
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December 05,2023
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 diagnosis and treatment plan.
A 60 year old female resident of suryapet farmer by occupation came to the OPD with
CHIEF COMPLAINTS :
Swelling of both legs since 20 days
Breathlessness since 3 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 years ago when she developed lower back pain which was sudden in onset gradually progressive no aggravating and relieving factors and she noticed decreased urine output that is not associated with frequency, urgency, burning micturition
There is bilateral pedal edema which was insidious in onset gradually progressive intially extending upto ankle then progressed to knee which was of grade 3
She has shortness of breath which was sudden in onset gradually progressive grade 3 aggravated on walking relevied by taking rest
Then she was taken to hospital where they diagnosed as kidney failure and was on medication for 6 months then started on dialysis twice a week
2 days backshe was brought to the hospital due to severe shortness of breath grade 4 aggravated on lying down position and slightly relieved on sitting
Presently Pedal edema in both legs extending upto the knee. She was having tremors of both hands and legs which are occurring infrequently
history of orthopnea present
No history of evening rise of temperature
No history of abdominal pain
PAST HISTORY : known case of hypertension since 1year
Not a known case of diabetes asthma epilepsy tuberculosis
TREATMENT HISTORY : On regular dialysis
She is on medication nifedipine and furosemide
PERSONAL HISTORY : Before illness : mixed diet, normal appetite, adequate sleep, regular bowel and bladder moments no addictions and allergies
After illness : Diet : consuming foods like idly milk in small quantities reduced appetite, reduced bowel and bladder
DAILY ROUTINE : BEFORE ILLNESS :
wakes up at 6 am does house hold work like cooking, washing utensils till 8:30am then she eats rice with pickle or curry as breakfast and then goes to field. Eats lunch at 1:00 pm and then comes back home at5:00 pm does house hold work and drinks a cup of tea. Dinner at 8:30 pm and goes back to sleep at 10:00pm
AFTER ILLNESS: stopped working 2 years back from then she just stays at home
FAMILY HISTORY : not significant
General examination : patient was conscious coherent cooperative thin built moderately nourished
Pallor present. Bilateral pedal edema present. No cyanosis clubbing lymphadenopathy
Vitals : pulse rate : 104 bpm
Respiratory rate : 32 cpm
Temperature : a febrile
Spo2 : 84%
Blood pressure : 100/80 mm hg
Systemic examination:
Cardiovascular system:
-S1,S2 heard .no mumurs.
Respiratory system:
-Position of trachea central.
- Bilateral airway entry present.
-Dyspnea present
- no wheeze.
Abdomen:
-Scapoid
-No tenderness
-No palpable mass
-Spleen : not palpable
-liver : not palpable.
CNS examination:
-Conscious .
-no signs of meningeal irritation.
Investigations:
PROVISIONAL DIAGNOSIS:
CKD STAGE 4 ON MHD
WITH ANEMIA OF CKD
HEART FAILURE HYPERTENSION SECONDARY TO CKD
TREATMENT :
Salt restriction<2gm/day
Fluid restriction<1.5 l/day
Tab. Lasix 40mg po BD
Tab. Nicardix 10 mg
Tab. Orofer XD po BD
Tab. Nodosis 500 mg po BD
Inj. Epo 4000 iv BD
Tab. Shelcal po OD
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