LONG CASE - A 22 year old female came to the OPD with chief complaints of generalised swelling over the body and decreased urine output and

 LONG CASE: FINAL PRACTICAL

MEDICAL CASE

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed 

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

Viharika Vupputuri

June 15 , 2022

Hall ticket no- 1701006197


CASE DISCUSSION

A 22year old female came to the OPD with the chief complaints of 

 Generalised swelling over the body since 6   days.

  Decreased urine output since 6 days.

   Shortness of breath since 5 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 days back and then she developed generalised swelling of the body and reduced urine output and shortness of breath.

No H/o cold, cough,fever, chest pain , orthopnea , palpitations.


PAST HISTORY

Known case of diabetes mellitus since 15 years on insulin.

Hypertension since 2years on Tab. Telma

 40mg and Tab. Nicardia 20mg.

Not a known case of asthma , tuberculosis and epilepsy.


PERSONAL HISTORY

Diet - Mixed 

Appetite - decreased

Bowel and bladder - decreased

No addictions 

No allergies 


FAMILY HISTORY 

Insignificant 

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative and is moderately built and nourished.

Patient is examined in a well lit room.

Pallor - present

Icterus - absent 

Clubbing - absent 

Cyanosis - absent 

Lymphadenopathy - absent 

Edema - present 


VITALS 

Temperature - afebrile 

BP - 180/100

Pulse rate - 86bpm

Respiratory rate - 24cpm

SYSTEMIC EXAMINATION

CVS 

S1,S2 sounds heard.

No murmurs 

No apex beat 

No palpable heart sounds


RS 

Bilateral Crepitus heard.


CNS 

Cranial nerves - intact 

Motor system - intact 

Superficial reflexes and deep reflexes are present.

No involuntary movements

Sensory system - pain , touch , temperature , vibration well appreciated.

ABDOMEN 

Inspection - 

Shape - distended

Flanks - full

Umbilicus - central position , inverted

No dialated veins, hernial orifice 

No visible pulsations. 


Palpation- 

No local rise of temperature

All inspectory findings are confirmed 

No guarding rigidity.

Deep palpation - no organomegaly 


Percussion - fluid thrill is present 


Auscultation - bowel sounds heard.


PROVISIONAL DIAGNOSIS - 

Chronic kidney disease with maintenance hemodialysis .

INVESTIGATIONS  

Hemogram  










CLINICAL IMAGES





VIDEO ELICITING EDEMA





Ultrasound




Chest X ray

            

                                   ABDOMEN






 TREATMENT 

Inj. LASIX 60mg IV/BD

Insulin infusion 6ml/hr 

Injection PIPTAZ 2.25gm /TID/I

Inj. PAN IV/B

Inj. ZOFER IV/TI

Tab. NICARDIA 20 MG /B

Tab. TELMA 40 MG /O

Tab. OROFER-X5 PO/O

Tab. NODOSIS 500 MG PO/B

Tab. SHELCAL 500MG/PO/OD

Nil by mouth till further orders 

Fluid and salt restriction 

GRBS monitoring regularly.










































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