45 YRS OLD FEMALE WITH CKD

 SNEHA CHAUHAN 

ROLL NO- 126

2017 BATCH

9th SEMESTER 

 CASE BLOG 

• This is an online E-log to discuss our patient’s de-identified health data shared after taking his/her/guardian’s 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 patients clinical problems with collective current best evidence based inputs. 
• This E-log also reflects my patient centered online learning portfolio and your valuable inputs on comment box are welcome. 
• I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis” to develop my competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan. 
• The patient and the attenders have been adequately informed about the documentation and privacy of the patient. No identifiers shall be revealed throughout this presentation. 

A 45 years old female, who is a hostel cook by occupation, came with chief complaints of leg swelling on both ankles since one year. 

History of presenting illness- 

Patient was apparently asymptomatic 1 year ago. Then she developed bilateral swelling of ankles that was

-insidious in onset, 

-gradual in progression, 

-non pitting type, 

-the patient decided to take a more conservative approach to help deal with the ankle swelling when that developed. 

• more recently, someone had advised her to get a dialysis done for which she came here. 
• The ankle swelling never really disturbed her usual routine life. 
• There is no swelling on other parts of the body.
• The ankle swelling is aggravated on doing activity usually, ans relieved on resting. 
• No changes in the morning or at night, and 
• Not associated with cramps, shortness of breath, fever, decrease of urine output. 

Past history-

• No history of similar complaints in the past (before the 1 year)
• She has a history of Hypertension since a year 
• No history of other systemic diseases such as diabetes, Asthma, Epilepsy, tuberculosis. 

Treatment history-

Nicardia for hypertension

Allergies history- 

No history of any known allergies

Family history-

Insignificant

Personal history-

• Appetite- Normal
• Diet- Mixed
• Sleep- Adequate
• Bowel and bladder movement- Regular
• No addictions as such. 

General physical examination- 

Patient is conscious, coherent and cooperative. 

VITALS-

• Heart rate- 120 beats per minute
• Respiratory rate- 16 cycles per minute
• Temperature- Afebrile
• Blood pressure- 120/91 mmHg

Pallor present- 

No signs of, icterus, clubbing, lymphadenopathy, cyanosis, 

Systemic examination-

Abdominal examination- 

Inspection- Scaphoid shape, no visible peristalsis 

Palpation- Soft, non tender, and no organomegaly

Percussion- no free fluid

Auscultation- bowel sounds heard. 

Respiratory examination-

• examination of nose and oral cavity- appear normal

• Inspection- 

1. Shape of chest- bilaterally symmetrical
2. Expansion of chest- appears equal on both sides
3. No crowding of ribs
4. No visible pulsation or engorgement 
5. No visible scars or sinuses

• Palpation of chest-

1. No tenderness 
2. No local rise of temperature 
3. Expansion of chest equal on both sides 
4. Apex beat- medial to mid clavicular line in the 5th intercostal space. 

• Percussion-resonant on all areas 

• Auscultation- Bilateral air entry, normal vesicular breath sounds. 

Cardiovascular system examination- 

• Inspection- no visible pulsation 

• Palpation- apex beat felt

• Percussion- heart borders are normal

• Auscultation- S1S2 heard, no added murmurs

Central nervous system examination- 

• Conscious 
• Normal speech 
• Cranial nerves intact
• Sensory and motor system- normal 
• Neck stiffness- absent
• Reflexes- normal

Investigations

Ultrasound Report Impression- Bilateral Grade 3 Renal Pelvic Diameter with simple renal cortical cysts

Treatment- 

1. Fluid restriction less than 1.5 L/day
2. Salt restriction less than 2g/day
3. Tab LASIX 40mg PO/BD
4. Tab NICARDIA 20mg PO/BD
5. Tab NODOSIS 500mg PO/BD