60 Year Old Female with CKD on Maintenance Haemodialysis......

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December 03, 2023

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.

A 60 year old female resident of suryapet farmer by occupation came to the OPD with

CHIEF COMPLAINTS :

Swelling of both legs since 20 days

Breathlessness since 2 days 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 3 years ago when she developed lower back pain which was sudden in onset gradually progressive no aggravating and relieving factors and she noticed decreased urine output that is not associated with frequency, urgency, burning micturition

There is bilateral pedal edema which was insidious in onset gradually progressive intially extending upto ankle then progressed to knee which was of grade 3

She has shortness of breath which was sudden in onset gradually progressive grade 3 aggravated on walking relevied by taking rest

Then she was taken to hospital where they diagnosed as kidney failure and was on medication for 6 months then started on dialysis twice a week 

Yesterday she was brought to the hospital due to severe shortness of breath grade 4 aggravated on lying down position and slightly relieved on sitting

Presently Pedal edema in both legs extending upto the knee. She was having tremors of both hands and legs which are occurring infrequently 

history of orthopnea present

No history of evening rise of temperature 

No history of abdominal pain 

PAST HISTORY : known case of hypertension since 1year

Not a known case of diabetes asthma epilepsy tuberculosis 

TREATMENT HISTORY : On regular dialysis

She is on medication nifedipine and furosemide 

 PERSONAL HISTORY : Before illness :  mixed diet, normal appetite, adequate sleep, regular bowel and bladder moments no addictions and allergies

After illness : Diet : consuming foods like  idly milk in small quantities reduced appetite, reduced bowel and bladder

DAILY ROUTINE : BEFORE ILLNESS :

wakes up at 6 am does house hold work like cooking, washing utensils till 8:30am then she eats rice with pickle or curry as breakfast and then goes to field. Eats lunch at 1:00 pm and then comes back home at5:00 pm does house  hold work and drinks a cup of tea. Dinner at 8:30 pm and goes back to sleep at 10:00pm

AFTER ILLNESS: stopped working 2 years back from then she just stays at home

FAMILY HISTORY : not significant

General examination : patient was conscious coherent cooperative thin built moderately nourished

Pallor present. Bilateral pedal edema present. No cyanosis clubbing lymphadenopathy 

Vitals :  pulse rate : 113 bpm

Respiratory rate : 32 cpm

Temperature : a febrile 

Spo2 : 84%

Blood pressure : 100/80 mm hg

  

   

   

Systemic examination:

Cardiovascular system: 

-S1,S2 heard .no mumurs.

Respiratory system:

-Position of trachea central.

- Bilateral airway entry present.

-Dyspnea present 

- no wheeze.

Abdomen:

-Scapoid

-No tenderness

-No palpable mass

-Spleen : not palpable

-liver : not palpable.

CNS examination:

-Conscious .

-no signs of meningeal irritation.

Investigations:

PROVISIONAL DIAGNOSIS:

CKD STAGE 4 ON MHD

WITH ANEMIA OF CKD

HEART FAILURE HYPERTENSION SECONDARY TO CKD

TREATMENT :

Salt restriction<2gm/day

Fluid restriction<1.5 l/day

Tab. Lasix 40mg po BD

Tab. Nicardix 10 mg

Tab. Orofer XD po BD

Tab. Nodosis 500 mg po BD

Inj. Epo 4000 iv BD

Tab. Shelcal po OD