70 year old female with pedal edema

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This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered 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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 


   CHIEF COMPLAINTS 

 -A 70 year old Female Patient came to OPD, for her regular check up

-She was admitted on the basis of deranged Renal Function Tests


  HISTORY OF PRESENTING ILLNESS

-The patient was apparently asymptomatic 2 years back, when she developed COVID -19, and went to a hospital where she was diagnosed with CKD, based on her raised Urea and Creatine. 

- she also mentioned that 4 years ago she  had a fracture of her left hand for which she got treated and been prescribed nsaids , which she is taking on and off since then.

- decreased urine output since 1 year 

- she also developed pedal edema 1 year back. 

-There is no history of fever, SOB, palpitations, Chest pain, cough or burning micturation


  PAST HISTORY

-The patient is a known Hypertensive since 2 years.

-The patient is not a known case of DM, Asthma, TB, Epilepsy 


  FAMILY HISTORY

-no relevant family history


  PERSONAL HISTORY 

-Diet - Mixed

-Appetite - Normal

-Bowel and Bladder - Regular

-Sleep - Adequate

-Addictions - None


  TREATMENT HISTORY

-patient is on medication for antihypertensives 


  GENERAL EXAMINATION

The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 


Moderately built and well nourished


Presence of pallor 


Edema of Lower Limbs is present , pitting type


No icterus, cyanosis, clubbing, lymphadenopathy.


  CLINICAL IMAGES 










VITALS:


Temp: Afebrile

PR: 126 bpm

BP: 130/90 mm Hg

RR: 38 cpm


SYSTEMIC EXAMINATION

Examination is done in a well lit room and sitting position 


RESPIRATORY SYSTEM

-bilateral air entry present

-normal vesicular breath sounds heard 


CVS 

S1 and S2 are heard 

No murmurs 


PER ABDOMEN

Inspection: Shape of Abdomen - Normal, No sinuses, fistulas. Umbillicus - Central, not everted


Palpation: Inspectory Findings Confirmed 

Soft, non tender

No Organomegaly


Percussion : Tympanic


Auscultation: Bowel sounds Heard 


CNS 

-No focal neurological deficits 


PROVISIONAL DIAGNOSIS

CHRONIC RENAL FAILURE- secondary to NSAID abuse


INVESTIGATIONS1

19/07/2021

21/11/2022

4/01/2023













                    





TREATMENT 

-Tab. LASIX 

-Tab. MINIPRESS 

-Tab. NODOSIS 

-Tab. SHELCAL 

-Tab. OROFER 

-Inj. EPO 

- Hemodialysis 




PROVISIONAL DIAGNOSIS

- CKD 2° TO NSAID ABUSE 

-  ANEMIA 2° TO CKD 

-  AKI ON CKD











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