A 60 year old female came to OPD for Dialysis

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians singned informed consent. Here we discuss our individual patients problems with an aim  to solve the patient’s clinical problem with collective current best evident based input.

This E blog also reflects my patient cantered 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. 

This is the case of a 60 year old female daily worker by occupation resident of 

CHIEF COMPLAINTS:

severe lower back pain, pedal edema, pain in lower limbs. 

HISTORY IF PRESENTING ILLNESS:

Patient was apparently asymptomatic 15 years ago. She then developed pain in lower limbs. Pain was of dragging type She was on medication for 5 years. 

10 years ago patient developed severe lower back pain, decreased urinary output and burning Micturition. She was taken to nalgonda government hospital. She was diagnosed with CKD and was on medication for 9 years. 

One year ago she had seizure. She was taken to hospital where she was diagnosed with complete renal failure and was suggested  kidney transplantation. 

Due to financial problems she refused kidney transplantation and continued medication for 6 months. 

The symptoms worsened and there was facial puffiness and complete urinary retention so 6 months ago she came for dialysis in Kamineni hospitals. 

Past history:

History of SOB. 

Generalized Weakness present. 

Known case of hypertension. 

History of hysterectomy

N/K/C/O diabetes, asthma, thyroid disorders. 

FAMILY HISTORY:

No family history. 

PERSONAL HISTORY:

Mixed diet

Loss of appetite

Inadequate sleep

Irregular bowl and bladder movements

No History of alcohol and tobacco addiction. 

GENERAL EXAMINATION:

Prior consent was taken and patient was examined in a well lit room.

Patient was conscious, coherent and cooperation.

Pallor present . No icterus, clubbing ,cyanosis.

No generalised lymphadenopathy. 

Bipedal edema present . 

VITALS :

Temperature- 98.6°F

BP-130/90

PR-84 bpm

RR-16 per min

Spo2-98%

SYSTEMIC EXAMINATION:

RS: Bilateral chest air entry, 

CVS: S1,S2 positive

PA: soft, no tenderness

CNS : NF NB

INVESTIGATIONS:

PROVISIONAL DIAGNOSIS :

Renal failure.