09/02/2022
Samhita Ghanathay
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35 year old female with complaints of Shortness of breath and decreased urine output.
I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.
Following is a brief about the case,
(History as per date of admission).
CHEIF COMPLAINTS:
35 year old female, resident of Nalgonda and a farmer by occupation, came to our hospital with chief complaints of:
* Shortness of breath since 20 days
* Bilateral pedal edema since 20 days
* Facial puffiness since 10 days
* Reduced urine output since 10 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 3 months ago when she had a sudden onset shortness of breath at night for which she was taken to a local doctor in the village. There, she was diagnosed with -
* hypertension- on regular medications
* Low hemoglobin - 2 units of blood were transfused
* Chronic kidney disease
Post transfusion, she developed bipedal edema - which did not reduced on medication. She was then taken to a hospital in Nalgonda. Here another unit of blood was transfused, but pedal edema did not relieve.
20 days back she developed b/l pedal edema, reduced urine output, sob a/w orthopnea, and PND, and facial puffiness.
10 days ago,she had a fever spike that subsided on medication.
She was then brought to our hospital, where she was put on dialysis and was transfused with 2 more units of blood, simultaneously.
Following this, her fever subsided completely, edema subsided partially and her breathing improved.
PAST HISTORY:
* There is no history of similar complaints in the past.
* She was diagnosed with hypertension 3 months ago, for which she is on regular medication.
* She is not a known case of Diabetes, Asthama, Epilepsy, Tuberculosis.
* No history of any previous surgeries.
PERSONAL HISTORY:
* Diet - Mixed
* Appatite - Normal
* Sleep - Reduced
* Bowel and Bladder - Reduced urination, normal bowel.
* Allergy - None
* Addictions - None
FAMILY HISTORY:
No history of similar complaints in the family.
GENERAL EXAMINATION:
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
She is sleeping comfortably on the bed.
She is moderately build and well nourished.
- Pallor-present
- Icterus-absent
- Clubbing-absent
- Cyanosis-absent
- Lymphadenopathy-absent
- Edema - pitting type present.
Vitals:
- Temperature -afebrile.
- Pulse rate - 89/ minute
- Respiratory rate - 21/minute
- Blood pressure (left arm) - 110/70 mm of Hg
SYSTEMIC EXAMINATION:
CVS: S1 and S2 heard. No addded thrills or murmurs heard
RESPIRATORY SYSTEM:
Normal vesicular breath sounds heard.
ABDOMEN:
*non tender
*firm
*mild Ascitis possible.
CNS:
Conscious and coherent.
Normal sensory and motor responses.
INVESTIGATIONS :
The investigation ordered are - ECG, USG, Renal function tests, Liver Function Tests, Hemogram with serum iron levels,.
ECG -
USG - Grade 3 RPD and gross ascitis.
RFT - raised Creatinine levels
LFT- increased Alkaline phosphatase and reduced proteins.
Hemogram - low hemoglobin.
PROVISIONAL DIAGNOSIS:
The patient is suffering from Acute kidney injury on Chronic kidney disease, with bipedal edema and hypertension.
TREATMENT:
Supportive care is given and patient maintained on hemodialysis.
8/2/2022:
*Fluid restriction - <1.5 L/day
* Salt restriction - <2gm/day
* Tab.Nicardia - 10 mg - PO -BD
* Tab.Nodosis - 500mg - PO - BD
* Tab.Livogen - PO - OD
* Tab. Shecal- CT - PO - BD
* Inj. Erythropoietin- weekly once
9/2/2022:
*Fluid restriction <1L/day
* Salt restriction <2.5 gm/day
* Tab.Nicardia - 10 mg - PO -BD
* Tab.Nodosis - 500mg - PO - BD
* Tab.Livogen - PO - OD
* Tab. Shecal- CT - PO - BD
* Inj. Erythropoietin- weekly once
She is currently on dialysis.
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