67/F with CKD on MHD since 2 years

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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

CHIEF COMPLAINTS: 
Patient came with complaints of: 
-decreased urine output since 3 months 
-bilateral swelling of lower limbs since 3 months 

HOPI: 
Patient was apparently asymptomatic 2 years back, then she developed decreased urine output, bilateral pedal edema and was diagnosed to have renal failure with heart failure and was in conservative management since 3 months the symptoms have progressed. Patient was initiated on hemodialysis. 


Past History: 
K/c/o DM2 since 25 years 
K/c/o HTN since 20 years 
On regular medication for both. 
N/K/C/O Asthma, CAD, CVD, Epilepsy, TB 

Personal History: 
Appetite: Normal
Diet: Non-veg 
Bowel: Regular 
Bladder: Decreased frequency
Sleep: Adequate 
Addictions: None

Family History:
Insignificant

Menstrual History: 
Last menstrual cycle: 20 years ago

General examination:
No Pallor, Icterus, Clubbing, Cyanosis, Lymphadenopathy. 
Edema of the legs- present 

Vitals at Admission: 
TEMP: 98.4F
BP: 130/60MMHG
PR: 91 BPM
RR: 16 CPM
SpO2: 95
GRBS: 230 mg/dl

Systemic Exam: 
CVS: S1S2 + 
RS: BAE + 
CNS: NFND 
P/A: Soft, Non-tender, No organomegaly


USG on 25/04/23: 
Impressions: 
1. Grade II RPD changes notes in bilateral kidney
2. Left renal calculi 
3. Right pleural effusion
4. Grade I fatty liver 

25/04/23: 

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP ASSESSMENT

INTERNSHIP ASSESSMENT: Neha Pradeep Roll number: 110 My medicine posting during my internship year extended from 12th of April 2023 to the 12th of June 2023.  My time in medicine was divided into 4 parts, with 2 weeks each.  June 12th- June 28th : (UNIT)  I was placed in second unit. In this unit, Dr. Abhinaya, Dr. Narsimha, Dr. Prachethan and Dr. Harika were my SR and PGs. In duty, my main learnings came from time spent in OP, casualty and monitoring of admitted patients in unit.  Since we didn't have any admissions in unit for my first two weeks, most of my experience came from OP.  Here, we took history, examined the patient with respect to their presenting complaints. Here we learnt how to localize the problem without requiring excessive investigations and medicating without over treating.  On our first OP day, a case was brought to casualty in an unresponsive state, with seizure like activity.  Handling this case taught us a few basics of first l...
Read more

BIMONTHY ASSESSMENT May 2021

Image
Neha Pradeep Roll no. 99 BIMONTHLY ASSESSMENT - MAY 2021 1) PULMONOLOGY: Case #1: https:// soumyanadella128eloggm. blogspot.com/2021/05/a-55- year-old-female-with- shortness-of.html   1) What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? 20 years ago First SOB episode lasted one week. It was relieved on taking medication. 19-13 years ago Similar episodes, SOB lasted approximately one week.  All episodes were relieved upon taking medication. 12 years ago Episode of SOB, lasted 20 days. She was hospitalized. SOB decreased upon treatment at the hospital. 11-9 years ago SOB episode, lasting almost a month. 8 years ago Diagnosed with diabetes. Presented with polyuria. 7-5 years ago SOB episode l...
Read more

Case: 80 year old man with lower back pain and breathlessness

Image
Neha Pradeep, MBBS 9th semester Roll no: 99 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome . 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 diagnosis and treatment plan. Case :  A 72 year old man, came with complaints of breathlessness and cough since 20 days and lower back pain since 10 days.  History of Presenting Illness:  A 80 ...
Read more