CKD case

06/06/2023


Hi, I am shaik karishma , 5th Sem Medical Student.This is an 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 patient's 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 the comment box is welcome.”

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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS
A 48 year old patient came with C/O  abdominal distension and decreased urine output since 6 days 

HOPI
patient was asymptomatic 6 days ago
she had SOB grade 4, cough, pedal edema which was pitting type.
He had vomiting of 2 episodes on 3/6/23 which was non projectile and non bilious with water,food etc content.
She had decreased urine output since 5 days
So she went to a hospital in Nalgonda where the referred her to go to KIMS for dialysis 

PAST HISTORY

2 years ago she had similar symptoms of pedal edema and abdominal distention and decreased urine output where  she was diagnosed with CKD and was managed conservatively
Known case of diabetes mellitus type 2 since ten yrs
No HTN,epilepsy,CAD,thyroid disorders 
No fever,diarrhoea ,constipation
And had vomitings of 2 episodes on 3rd june


TREATMENT HISTORY

DM 2 since 10yrs
No HTN,CAD,TB,asthma
No chemoradiation no blood transfusion
Surgery hysterectomy 20yrs ago

PERSONAL HISTORY

married
Normal appetite
Mixed diet
Regular bowel
Normal sleep
Decreased micturation
No known allergies,addictions,alcohol occasionally

FAMILY HISTORY

no significant family history

Sibling history healthy

PHYSICAL EXAMINATION

GENERAL EXAMINATION
conscious coherent cooperative
Pallor yes
No icterus,cyanosis,clubbing of fingers,lymohadenopathy
Edema pitting type

VITALS
pulse 89bpm
BP
temp febrile
Respiration 20 per min

SYSTEMIC EXAMINATION

CVS
no thrills
S1 s2 postive
No cardiac murmurs

Respiratory system
Dyspnoea no
No SOB
no wheezing
Centrally placed trachea
Breath sounds vesicular

Abdomen
Shape obese
Tenderness
Palpable mass
Free fluid
Bruits
Hepatosplenomegaly
Bowel sounds

INVESTIGATIONS 


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