Case history-5
This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.
A 50 year old female has come to casualty with shortness of breath and swelling in lower limbs (pedal edema) since 4 days .
Patient complaints of decrease in urine output since 4 days.
PAST HISTORY :
Patient compliant of hypertension since 7 years.
No history of diabetes, asthma, Tuberculosis, coronary artery disease.
No history of blood transfusion and atherosclerosis.
PERSONAL HISTORY:
Appetite : normal
Diet : mixed.
Bowel and bladder movement: normal.
Addictions : patient takes alcohol regularly.
FAMILY HISTORY:
No history of diabetes, hypertension, asthma, tuberculosis in the family.
No history of heart diseases , stroke, cancer .
TREATMENT HISTORY:
Patient is not allergic to any known drugs.
Patient has not undergone any surgeries .
Patient doesn't use any antibiotics and not undergone any chemotherapy or radiation.
GENERAL PHYSICAL EXAMINATION:
Patient is cohorent , concious and cooperative and examined in well lit room.
Presence of pedal edema in lower limbs .
No pallor, cyanosis, icterus , clubbing.
No General lymphadenopathy.
VITALS:
Temperature: 98.6 degree Fahrenheit.
Respiratory rate:22/min.
Blood pressure:140/90mmHg
Pulse:84/min.
SpO2:94%
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills and cardiac mummers .
S1 and S2 are heard .
Respiratory system:
No wheezing and dyspnoea.
Positioning of trachea is central and breath sounds are vesicular.
Abdomen:
Shape of abdomen: obsese.
No tenderness and no palpable mass is present.
No free fluid and bruits and liver and spleen are not palpable and bowel sounds are not heard .
Central nervous system:
Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
Sensory and motor system are normal and glass -gow scale show 15/15.
PROVISIONAL DIAGNOSIS:
CKD ( chronic kidney diseases) and MHD ( maintenance haemolysis).
INVESTIGATION:
ULTRASOUND:
HBsAg- RAPID
FINAL DIAGNOSIS:
CKD ( chronic kidney disease)
TREATMENTS:
Fluid restriction: <1.5lit/day.
Salt restriction:<2gm/day
Tab.LASIX 40mg*Po*OD
Tab.NICARDIA 20mg*PO*BD.
Tab. NODOSIS 500mg*PO*OD
Tab.Bio D3 0.25mg*PO*BD.
PLAN OF CARE:
Haemodialysis.
Comments
Post a Comment