A 59 years old female with Decreased urinary output

 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 reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.

June 11, 2022

Name :- P. Sai Krupa Sri

Hall ticket number :- 1701006136 


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 a diagnosis and treatment plan.


Following is the view of my case :


CASE PRESENTATION:

A 59 years old female who is a house maker resident of nalgonda came to the opd with chief complaints of  

• Generalized weakness since 6 months 

• Facial puffiness and swelling of legs  since 6months 

• Decreased urinary output since 3 months

                Time line of events 

 



History of present illness :- 

Patient was apparently asymptomatic 1year back later she went to a local rmp for regular checkup and there she was diagnosed with hypertension and was on medication 

Tab nifidepine 10mg

Tab furosemide 40mg

6 months back  patient complaint of decreased food intake , weakness , puffiness of face and legs so went to near by hospital. But there was no improvement  

5 months back  they went to Miralguda hospital  with weakness , reduced food intake,  reduced urinary output , and puffiness of face and swelling of legs which is pitting type below the knees , doctor told that her kidneys were not functioning properly so she was put on medication as there was no improvement 

They came to Kamineni Hospital in the month of April  

Here the patient was put on dialysis which was done weekly 2 times.



Daily routine :- 

Patient usually wakes up at 5 am and will do household works  and  have breakfast along with coffee at 8:00 am again continues her household work and then she will have her lunch which is  rice and dal at 1:00pm and then takes a nap again continues her work then will have her dinner which is rice and dal at 8:30 pm and goes for sleep at 10:00pm 

Past history:- 

Known case of hypertension since 1 year

 Not a known case of Diabetes mellitus, asthma, epilepsy, TB

No history of similar complaints in the past

No previous surgical history


Personal history:- 

Diet- Mixed

Appetite- Decreased since 1month 

Bowel :- Regular 

Bladder movements- Urine frequency is reduced since 3 months  

Sleep- Adequate

No Addictions

No history of drug or food allergies


Family history :-

No similar complaints in the family


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

Pallor - present

Pedal edema- present- bilateral pitting type

No history of  cyanosis, clubbing and lymphadenopathy


Vitals

Temperature- Afebrile

Blood pressure- 150/90 mm of Hg

Pulse rate- 86 bpm

Respiratory rate- 21 cpm

SpO2 - 98% at room air 


Systemic examination :- 

• Abdomen examination:- 

On Inspection:

-Shape of the abdomen -Distended

-Movements of abdominal wall- moves with respiration

-Skin is smooth

-No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites

On Palpation:

-Inspectory findings are confirmed

-Soft and non tender

-No palpable mass

-No hepatosplenomegaly

On percussion:

 -Dullness is noted 

On auscultation:

-Bowel sounds heard


• Cardiovascular system examination:

-S1 and S2 sounds are heard

-No murmurs


• Respiratory system examination:

-Bilateral air entry present

-Normal vesicular breath sounds are heard


• Central nervous system examination:

-No focal neurological deficits


Clinical pictures :- 













Investigations:- 

Complete blood picture:-

Hemoglobin :-4.5 gm/dl 

Total count :- 7000 cells/cumm 

Neutrophils :- 86% 

Lymphocytes :- 12%

 Eosinophils :- 0% 

Monocytes :- 02 %

Basophils : 0 % 

PCV :- 13.7 vol % 

MCV :- 83.5 fl

 MCH :- 27.4 pg 

MCHC :- 32.8 % 

RDW-CV :- 15.8 %

RDW -SD :- 47.5 fl

RBC count :- 1.64 millions/ cumm

Platelet count :- 28000


Impression :- Normocytic normochromic anemia with neutrophilia, thrombocytopenia











Provisional diagnosis :- 

Chronic kidney disease secondary to hypertensive nephropathy ?


Treatment :- 



2nd June 


1. Tab Nodosis 550mg/PD/TID 

2. Tab Pan 40mg /PR/OD 

3. Tab Lasix 4mg/Pd/BD 

4, Tab Nicardia 10mg/PO/BD 

5. Tab Arkamine 0.1mg/PD/OD 

6. Tab Zofar 4mg /PD/SOS 

7. Tab MVT /PD/OD 

8. 2 PNBC 1 SPP Reserve 

9. 1PNBC intradialysis transfusion 

10. 1 SDP Transfusion



3rd June 


1. Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT/ PD/OD 

9. 1 PRBC reverse and 1 CDI Transfusion 

10. Inform SOS 

11. 1 PRBC transfusion intradialysis



4th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD 

9. 1 PNBC intra dialysis planned for tomorrow morning



5th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD



6th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD



7th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD


8th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD


9th June 


1.Tab Nodosis 550mg/PD/TID 

2.Tab Pan 40mg /PR/OD 

3.Tab Lasix 4mg/Pd/BD 

4.Tab Drofen - YT/PD/OD 

5.Tab Nicardia 10mg/PO/BD 

6.Tab Arkamine 0.1mg/PD/OD 

7.Tab Zofar 4mg /PD/SOS 

8.Tab MVT /PD/OD










Instrument pictures :- 























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