A 35 year old female with Pedal edema since 20 days, Decreased urinary output since 20 days, shortness of breath, Facial puffiness.

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.

CHIEF COMPLAINTS

A 35 year old female came to casualty with 

Bilateral pedal edema since 20 days,

Decreased urinary output since 20 days,

shortness of breath, and Facial puffiness.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic until 2 months back and then she developed chest pain for which she visited local hospital in miryalguda, where she was diagnosed with chronic kidney disease and low hemoglobin, 2 PRBC transfusions were done.

After the blood transfusion, she developed bilateral pedal edema which subsided on medication.

20 days back she developed Bilateral pedal edema, Decreased urinary output, shortness of breath (orthopnea and nocturnal dyspnea).

10 days back she developed Fever not associated with chills and rigor, which subsided on taking medication.

1 PRBC transfusion was done in the Nalgonda hospital.

PAST HISTORY

Hypertensive since 3 years

Not a known case of asthma, diabetes, TB.

PERSONAL HISTORY

Adequate diet before developing of symptoms

mixed diet

regular bowel and bladder movements

sleep adequate

no consumption of alcohol and smoking

FAMILY HISTORY

No history is seen in family

No cases of hypertension and diabetes

TREATMENT HISTORY

Previously seen by a doctor and subsided on taking medication.

PHYSICAL EXAMINATION

GENERAL

Patient is coherent, cooperative and conscious.

proper nourishment and proper build is seen.

pallor   - Present



Icterus    - absent

Lymphadenopathy- absent

clubbing - absent



cyanosis - absent

Pedal edema  - Present




VITALS

Afebrile

BP- 170/100 mm Hg

PR-99 bpm

RR- 22 cpm

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM-shortness of breath

CVS-S1,S2 +

RR- 16cpm

Spo2 -98%

RS: BAE+

P/A: SOFT, NON TENDER

CNS- NAD

# Outside reports on 30/11/21:










On 02/12/21:




On 17/12/21:


On 18/12/21:



PROVINSIONAL DIAGNOSIS

Acute Kidney injury on CKD

TREATMENT:

1) Fluid restriction < 1.4 L/day
2) Salt restriction  <2.4 gm/day 
3) Inj.Lasix 40 mg PO/BD
4) Tab.Nicardia 10 mg Po/Tid
5) Tab.SHELCAL- CT PO/OD
6) NEB. WITH SALBUTAMOL 2 RESIPULES/4TH HRLY
7) TAB.NODOSIS 500 MG PO/OD
8) Inj. PIPTAZ 2.25gms IV BD
9) Head end elevation upto 30'
10) O2 supplementation if SpO2 < 90%

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