38 years old female with CKD on MHD

This is 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.

Vignatha 9th semester

roll no: 45

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.

Following is the view of my case:

A 38 year old female shopkeeper from miryalaguda came to the hospital for her regular session of hemodialysis.

History of presenting illness:

 Patient was apparently asymptomatic 4 months back then she noticed :

                 swelling of her lower limbs,

                 she also had few episodes of vomiting immediately after having food

                 she  was unable to flex her legs and she found difficult in squatting 

                 she used to feel drowsy and sleeps for prolonged period  .But she neglected all those symptoms . she went to a government hospital and got treated and then after two days she was fine.

On the next day blood test was done which suggested that her hemoglobin levels were very low and the doctor advised her for tranfusion of blood.

So she presented to our hospital then after a thorough examination and investigations it was found that her hemoglobin levels were 3-4% and was diagnosed with ckd.

Past history: she is a known case of pcos. And she's hypertensive since 1 month.

There was a history of eczematous rash 4 months ago which was associated with severe itching. For that reason she took some homeopathy medications and the rash didn't get cured completely. 

Personal history:

Diet is mixed 

Appetite is decreased

Sleep is disturbed due to shotness of breath.

Bowel movements : normal 

Bladder movements: decreased frequency of micturition.

No addictions. 

She used to wakeup at 6am every morning and does all her house hold work like every other person. Then at 9 am she goes to her shop and stays there until 2 pm and she takes her lunch and she takes a nap.Then she goes to her work again. And goes to bed by 9pm. This was her daily routine when she had no health complaints.

Family history:

Insignificant.

Treatment history:

She used homeopathy medications for pcos and eczematous rash. Her pcos subsided and rash didn't subside. 

Allergy history: 

She's allergic to diclofenac sodium.

Citrezine and betnisol was given to control it.

General examination 

Patient is conscious coherent and cooperative well oriented to time place and person.

She is moderately bulit and moderately nourished.

Pallor is present.

No icterus, cyanosis, clubbing and lymphadenopathy and there is generalised edema in the body.

Vitals

Pulse: 92 beats per minute 

Respiratory rate: 40cycles per minute 

Blood pressure:

Temperature: afebrile 

Systemic examination 

CVS: s1 and s2 heard, no added murmus.

Respiratory system: normal vesicular breath sounds. Trachea central in position. No added breath sounds. No wheeze.

Per abdomen: distended. No tenderness. No palpable masses. Liver and spleen are kot palpable. Bowel sounds normal. 

CNS: higher motor functions normal. Motor and sensory system normal.

Investigations 

Serum creatine

Blood urea

Hemoglobin

Serum electrolytes

Random blood sugar

HBsAg- rapid

Anti HCV antibodies 

HIV Rapid

USG report

Hemodialysis charts

Diagnosis 

CKD on MHD 

Acute heart failure?

Treatment:

Tab.lasix 40mg

Tab.nicardia 10mg

Tab. Nodosis 550mg

Inj.erythropoietin 4000 IU subcutaneously weekly once

Tab.orofer xt

Tab.shelcal