28 year old female with Chronic Kidney Disease and Hypertension

23/10/2022
Student Name- D.Vineesha Chowdary 
2017 batch


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 evidence based input
This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the 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. 

Chief Complaints-


A 28 yearly female presented to the OPD with chief complaints of-
-Head ache since 20 days
-Generalized weakness since 20 days
-Supra pubic pain since 10 days
-Orthopnea since 7 days

History of presenting illness-

Patient was apparently asymptomatic 20 days ago when she developed when she developed headache which was insidious in onset and gradual in progression. 
It was associated with generalised weakness.
She later developed supra pubic pain in the abdomen since 10 days which was non radiating in type.
Then she developed orthopnea since 7 days which was relieved on sitting up.

Past history-

K/C/O hypertension since 3 months, not on any medication.
Not a K/C/O of DM, TB, Epilepsy, Asthma.

Personal History-

Appetite- Decreased appetite
Diet- Mixed
Bowel movements- Regular
Bladder movements- Normal
Sleep- Adequate
Addictions- No addictions
Allergies- No known allergies

Family History-

No significant family history.


General examination-

Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built

Vitals-

On 13/10/22
Temperature- Afebrile
Blood pressure- 200/110 mmHg
Pulse rate- 98 bp
Respiratory rate- 16 cpm
SpO2- 98%

Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent

Systemic Examination-

ABDOMINAL EXAMINATION-

INSPECTION- Umbilicus inverted , No abdominal distention, no visible pulsations, scars and swelling.

PALPATION-  Soft, non tender, no organomegaly.

AUSCULTATION- Bowel sounds heard

CVS EXAMINATION-

INSPECTION- No visible pulsations, scars, engorged veins. No rise in JVP. 

PALPATION- Apex beat is felt at 5th Intercoastal space medial to mid clavicular line.

AUSCULTATION- S1, S2 heard, no murmurs.

RESPIRATORY SYSTEM-

INSPECTION-  Shape of chest is elliptical, b/l symmetrical.

PALPATION- Trachea is central. Expansion of chest is symmetrical.

  Bilateral Airway Entry - positive

AUSCULTATION- Normal vesicular breath sounds.

CNS EXAMINATION-

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.


Investigations-

HAEMOGRAM-






RFT-






LFT-






ABG-






ECG-






2D-ECHO-






ULTRASOUND-







Provisional Diagnosis-

Chronic Kidney Disease with Hypertension

Treatment-

1) INJ.LASIX 40MG IV/BD
2) INJ.PIPTAZ 2.25GM IV/BD
3) TAB.DOLO 650MG PO/BD
4) FLUID AND SALT RESTRICTION
5) TAB.NICARDIA 10MG PO/BD
6) TAB.NODOSIS 300MG PO/BD

UPDATE-

Death of patient occurred on 16/10/22 at 1:48pm.

IMMEDIATE CAUSE OF DEATH- SEPTIC SHOCK WITH UREAMIC ENCEPHALOPATHY

ANTECEDENT CAUSE OF DEATH- CHRONIC KIDNEY WITH HYPERTENSION



















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