1801006085 - SHORT CASE

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

This E blog also reflects my patient-centered online learning portfolio and your valuable input in 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

 

CASE REPORT

 A 60 years old female patient , who is a retired weaver by occupation (retired 4yrs ago) presented to OPD with 

CHIEF COMPLAINTS :

• B/L Pedal oedema since 4 months                 
• Shortness of breath since 6 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 9 years ago , then she felt dizziness for which she went through a general check up and was diagnosed with Hypertension and Diabetes mellitus and is on medication since then.

5 years ago she had frequent episodes of dizziness which was associated with vomiting (nonprojectile) and photophobia. These episodes reccured for a duration of 5 to 6 days.

Then she visited our hospital, admitted for 6 days and discharged (diagnosis unknown) with medication : Clopidogrel 75mg , Betahistine and Aspirin.

No H/O fever, headache.

Since 3 months there is H/O Bilateral Pedal oedema which gradually progressed upto thighs.

There is H/O a shortness of breath (grade 3)since 6 days which was insidious in onset, aggravated on lying down and relieved temporarily on sitting and meditation.

No H/O cough , sputum.

H/O decreased urine output and lower backache since 5 days.

PAST HISTORY :

No similar complaints in past

H/O Diabetes since 9 yrs and Hypertension since  10 years.

Not a known case of thyroid , asthma , TB , cardiovascular disease. 

TREATMENT HISTORY :

On medication for Diabetes (Inj. Human Mixtard 40IU/ml) and for hypertension (Amlodipine 5mg) ; clopidogrel , aspirin.

No H/O any surgeries in past.

No H/O any drug allergies.

PERSONAL HISTORY :

Diet - Mixed

Appetite - Normal

Sleep - Adequate 

Bowel & Bladder habits - Regular ; decreased urine output.

Addictions - Occasionally alcohol 9 yrs back.

FAMILY HISTORY :

No significant family history.

GENERAL EXAMINATION 

Patient is conscious, coherent and co operative well oriented to time place and person.

Well built and nourished

Pallor - present 

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - No palpable lymph nodes

Edema - Bilateral pedal oedema (pitting type).

VITALS :

Temperature - afebrile

BP - 120/80 mmHg

RR - 24 cpm

PR - 83 bpm

SYSTEMIC EXAMINATION 

Respiratory system 

Bilateral airway entry - present                                   Normal vesicular breath sounds heard all over the chest.

CardioVascular System :

Apex beat not visible on inspection and is diffuse on palpation.

S1 and S2 heard.

No palpable murmurs.

Central Nervous System :

No focal neurological deficits 

Speech - Normal (coherent)

Per abdomen :

No tenderness 

No pain

No palpable organs

Bowel sounds - heard

PROVISIONAL DIAGNOSIS :

Chronic Kidney Disease secondary to Diabetic Nephropathy (k/c/o DM since 9 yrs and HTN since 10 yrs); with anemia ; with history of CVA.

INVESTIGATIONS :

Serum creatinine : 4.3 mg/do

Hb : 9.1gm/dl

RBC Count : 3.6million/mm3

Blood urea : 123mg/dl

Sodium : 138mEq/L

Potassium: 3.7 mEq/L

Phosphorus: 4.4mg/dl

Calcium : 9.9mg/dl

TREATMENT :

Inj. LASIX 40mg IV TID

Tab. NODOSIS 500mg PO BD

Tab. Amlong 5mg PO BD

Inj. HAI S.C (according to GRBS 6th hourly before meal)

Tab. CLOPITAB - A (75/20) PO

Tab. Shelcal PO OD

Tab. Orofer PO OD

Cap. BIO - D3 PO OD