PREFINAL EXAMINATION

PREFINAL EXAMINATION:

Date:4/1/23

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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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.

                                                              CASE REPORT

50yr old female patient, resident of suryapet, was a farmer by occupation (stopped 3yrs ago) came to the casualty with 

CHEIF COMPLAINTS :

Back pain since 3 years

B/L pedal edema since 7 days       

                                

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 years back then she developed back pain which was insidious in onset and gradual in progression and burning type of pain  not associated with any aggravating and reliving factors , used to regularly use prescribed NSAID tablet for back pain (two tablets everyday for the past 3 years )

H/o bilateral pedal edema , pitting type , on admission grade 3? Presently grade 2  since 7 days

H/o decreased urine output since 1 year , nocturia since one year (5-6 episodes each night)  

h/o loss of appetite and lethargy since 1 year 

No h/o burning micturition , shortness of breath , orthopnea , insomnia , headache , fever 

 

PAST HISTORY:

hypertension (de novo)

n/k/c/o Diabetes mellitus , epilepsy , asthma , tuberculosis 

FAMILY HISTORY:

not significant family history 

PERSONAL HISTORY:

diet : mixed

appetite : decreased appetite since 1 year 

bladder : normal 

bowel movements : normal 

addictions : not known 

allergies : not known 

GENERAL EXAMINATION: 

Patient is conscious coherent cooperative and well oriented to time ,place and person , moderately build and nourished

Pallor : present

Icterus, clubbing,cyanosis,lymphadenopathy  absent 

bilateral pedal edema present , pitting type , grade 2 (below the knee)

Vitals (4th january - 8:00am )

BP: 130/90 mmHg

RR: 15 cpm

PR: 88 bpm

Temp: afebrile 

Spo2: 100 

Systemic examination :

Cardiovascular system 

S1 , S2 heard 

no murmurs 

respiratory system 

BIL +

position of trachea : central 

breath sounds : vesicular 

per abdomen

-shape of abdomen : ovoid 

-no engorged veins , discharging sinuses and fistulas

  CNS 

-no focal neurological defect 

-all higher mental functions present 

reflexes 

                    right          left

biceps          +2               +2

triceps         +2               +2

supinator    +2              +2

knee             +2              +2

ankle            +2             +2

Investigations 

22/12:

23/12:

27/12:

29/12:

31/12:

1/1:

HEMODIALYSIS:

PROVISIONAL DIAGNOSIS:

CKD 2°  NSAID abuse , denovo HTN

Treatment:

22/12:

1)Fluid restriction <1.5 U/ day

2) salt restriction <2.5U/day

3) Inj. LASIX 40mg IV / TID

4) T. NICARDIA 10gm PO/TID

5)T.SHELCAL 500 MG PO/OD

6) Cap. Bi0-D3 PO / weekly once

7) T. NODOSIS 500 MG PO/BD

8) T. METXL. 50mg PO/OD

9) I/0 moniting.