A 70 year old female with CKD


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.




This E blog 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 diagnosis and treatment plan. 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.





 A 70 year old female patient came to general medicine OPD with chief complaints of


Shortness of breath since 1 month

Generalised body swelling since 10 days

Chest pain and palpitations on and off since 1 month

Vomitings 2 episodes, 1 month back

HOPI
Patient was apparently asymptomatic 1 month ago and then developed SOB grade IV for which she was taken to local hospital and got treated conservatively for raised creatinine and then SOB got relieved temporarily.
Again after 10 days developed SOB and for which she was taken to hospital to see the creatinine levels raised and adviced for dialysis and they denied and was discharged after consecutive management and decreased symptomatically.
After 10 days developed swelling of both lower limbs and abdominal distention and both upper limbs edema for which taken to hospital and foleys was placed as patient was bed ridden (since 1 month due to generalised weakness and decreased power in both lower limbs)
And now came with chief complaints SOB grade IV and generalised anasarca since 1 month.

HISTORY OF PAST ILLNESS
Pt is a k/c/o HTN and DM since 1 month
There is history of filariasis of left lower limb, 40 years ago.

TREATMENT HISTORY
Htn - T. Amlong 5mg
CAD - T. Ecospirin
            T. Metazoline 2.5mg
            T. Metaprolol 25mg
            T. Torsemide 10mg
            T. Clopitab

PERSONAL HISTORY 

Married
Appetite - normal
Diet - mixed
Bowels - Regular
Micturition - Normal
No known allergies 
No addictions

FAMILY HISTORY 
Not significant 

PHYSICAL EXAMINATION 

No pallor
No icterus
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
Oedema of feet



VITALS
Temp - 98.6 F
PR - 86/min
RR - 16/min
BP - 110/70mmHg

SYSTEMIC EXAMINATION 

CVS 
Cardiac sounds - S1 S2 +
Cardiac murmurs - not heard








RESPIRATORY SYSTEM
Dyspnea - present
Breath sounds - vesicular

ABDOMEN
Shape - distended
No tenderness
No palpable mass
Free fluid - present
LIVER- not palpable
SPLEEN- not palpable
Bowel sounds - heard

CNS
Level of consciousness- irritable
Speech- normal
Neck stiffness- absent

PROVISIONAL DIAGNOSIS 

CKD secondary to HTN and DM Nephropathy


INVESTIGATIONS









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