A Case of Chronic Kidney Disease
Welcome to my blog! I am Varshitha Kalidindi, a 2nd year medical student. This is an e-log to discuss our patient's de-identified health data after taking informed consent of the patient. It also reflects patient centered online learning portfolio.
I will be looking forward to some feedback and valuable inputs through the comments box provided below.
I will be looking forward to some feedback and valuable inputs through the comments box provided below.
I have been given this case 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, diagnosis and treatment plan.
CASE:-
A 45 year old female came to the OPD with chief complaint of weakness since 3 months. She also had pedal edema, reduced urine output and shortness of breath since 4 days. She was diagnosed with CKD 3 months ago and is on MHD (Maintenance Hemodialysis).
HISTORY OF PRESENT ILLNESS:-
The patient was asymptomatic until 3 months ago, when she started feeling weak. She is a housewife and, as stated by her daughter-in-law, she just cooks, eats and just spends the day either sleeping or just watching people move about in the house.
She went to the hospital complaining of weakness and was then told that she has a kidney problem. She has been on MHD since.
She has bilateral pedal edema and reduced urine output. She also has shortness of breath. She is on MHD at present.
She was sent to her first dialysis session in this hospital on 20/10/2021.
HISTORY OF PAST ILLNESS:-
She is not a known case of diabetes mellitus, hypertension, CAD, TB
TREATMENT HISTORY:-
She has not received any treatment for any problems in the past.
PERSONAL HISTORY:-
Appetite: decreased
Diet: vegetarian
Bowels: regular
Micturition: decreased
No known allergies, habits or addictions.
FAMILY HISTORY:-
No family history of diabetes, hypertension, heart disease, stroke, cancers, tuberculosis, asthma
PHYSICAL EXAMINATION:-
No icterus, cyanosis, clubbing, lymphadenopathy.
Pallor and pedal edema were found.
VITALS:-
Temperature: afebrile
Pulse rate: 92bpm
Respiratory rate: 24breaths/min
BP: 140/90 mmHg
SPO2: 98%
GRBS: 126mg%
SYSTEMIC EXAMINATION:-
CVS: S1, S2 sounds heard
Respiratory system: Dyspnoea present, position of trachea is centrral and breath sounds are vesicular.
Abdomen: shape of abdomen is scaphoid, bowel sounds are heard, genitals are normal
CNS: The patient is alert
DIAGNOSIS:- CKD on MHD
INVESTIGATIONS:-
Blood grouping and Rh type:-
TREATMENT:-
On 18/10/2021 -- Tab LASIX 40mg/PO/BD
Tab PAN 40mg/PO/OD
Tab SHELCAL CT PO/OD
Tab OROFER XT PO/BD
Inj. ERYTHROPOIETIN 4000 IU, SC weekly once
Inj. IRON SUCROSE 100mg in 100ml/NS/weekly twice
Tab NODOSIS 500mg PO/OD
On 20/10/2021 -- Tab LASIX 40mg PO/OD
Tab PAN 40mg PO/OD
Tab SHELCAL CT PO/OD
Tab OROFER XT PO/BD
Inj. Erythropoietin 4000 IU, SC/weekly once
Inj. IRON SUCROSE 100mg in 100ml/NS/weekly twice
Tab NODOSIS 500mg PO/OD
CLINICAL FINDINGS:-
45/F was brought to the OPD with complaints of fatigue. It was associated with pedal oedema, decreased urine output and shortness of breath since 4 days. At present, the patient is on MHD (Maintenance Hemodialysis). Also, the patient is finding it difficult to speak and respond to questions, so the caretaker, who is the patient's daughter in law, is answering for her and taking care of her.
Personal history: Diet is vegetarian. Appetite is decreased. Micturition is decreased. Sleep is adequate. Bowel movements are regular. No habits or addictions.
Examination: The patient is conscious and alert.
Pallor and pedal edema are seen. No icterus, cyanosis, lymphadenopathy, clubbing
Vitals: Temperature: afebrile
Pulse rate: 92bpm
Respiratory rate: 24breaths/min
BP: 140/90 mmHg
SPO2: 98%
GRBS: 126mg%
CVS: S1, S2 sounds heard
Respiratory system: Dyspnoea present, position of trachea is central and breath sounds are vesicular.
Abdomen: shape of abdomen is scaphoid, bowel sounds are heard, genitals are normal
CNS: The patient is alert
Investigations:-
Blood grouping and Rh type: O positive
Anti HCV Antibodies - RAPID: Non reactive
Hemogram on 21/20/2021: Haemoglobin, PCV, MCV, RBC count are reduced. RDW-CV is elevated
HBsAg-RAPID: Negative
HIV 1/2 Rapid Test: Non-reactive
Serum iron: 75μg/dl (37-145μg/dl)
RFT: Urea, creatinine, uric acid and phosphorous are elevated
Complete Urine Examination (CUE): Albumin and red blood cells were found in urine
ECG: normal
Hemogram on 19/10/2021: Haemoglobin, neutrophils and RDW-CV are elevated. Lymphocytes, PCV, MCV and RBC count are decreased
Ultrasound report: a 30mm simple renal cortical renal cyst was found in interpolar region of left kidney.
Diagnosis:- Chronic Kidney Disease (CKD) on Maintained Hemodialysis (MHD)
Treatment: Patient was given loop diuretic, alkalinising agent, proton pump inhibitor, erythropoietin and supplementation of iron, folic acid and calcium.
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