22 yr old ckd patient
(LONG CASE)FINAL MBBS PART 2
KNRUHS
PRACTICAL EXAMINATION.
1701006186
A Case of 22year Old Female with blurring of vision.
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.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 a diagnosis and treatment plan.
This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians 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 the patients clinical problem with current best evidence based input.
This Elog also reflects my patient centered online learning portfolio.
History of present illness
Patient was apparently asymptomatic 10 months back when she developed blurred vision which was insidious in onset gradually progressive not associated with any aggrevating and reliving factors.
Initially while writing degree final year exam she noticed blurring of vision,for which she visited ophthalmologist where she found to have high blood pressure then based on fundoscopic examination, investigation report doctor refferd her to nephrologist where she was diagnosed with derranged kidney function.
She is undergoing dialysis twice a week.
On prolonged sitting she developed edema in the leg which is of pitting type.
Past history :
No history of Bronchial asthma,Diabetes, Epilepsy.
Personal history
Her appetite is normal
She takes mixed diet
Her bowel and bladder movements are regular
No known allergies
Family history
Her father is a known case of hypertension.
General examination
Patient is conscious coherent and coperative ill built and moderately nourished
Vitals
Temperature Afibrile
Pulse rate 82 bpm
Respiratory rate 18cpm
Bp 110/70mmhg
Spo2 99%in room air
No pallor
No icterus
No cyanosis
No clubbing
SYSTEMIC EXAMINATION
Systemic examination:-
-CVS
S1 and S2 are heard
no thrills and no murmurs
-Respiratory
Trachea is in central position
Vesicular breath sounds heard
No added sounds
-Abdomen
No tenderness
No rise in temperature
No palpable mass
No scars and sinuses
No visible pulsations
no free fluid
liver and spleen are not palpable
bowel sounds are heard
-CNS
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
INVESTIGATIONS-
USG REPORT-
Lf kidney
RT kidney
Decreased in size both kidneys,CMD lost,PCS normal.
Provisional diagnosis :
Chronic kidney disease on hemodialysis.
TREATMENT given: a
Kind
1.Fluid restriction less pl than 1.5 lit per day
Salt restriction less than 2gm per day
Tablet lasix40 mg po bd
Tab Nicardia 20 mgPo tidi
Tab Nodosi 500 mg po bd
Tab Arkamin po bd
Tab orofer - xt po od
Cap bio d3 po od
