A 60 HR OLD FEMALE WITH ANEMIA SECONDARY TO CKD

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box"

A 60 yr old female came to opd with the 
Chief complaints:
-Shortness of breath on exertion grade 2-3 MMRC  since 5 days
-B/L Pedal edema worsening   since  5 days 
-Decreased urine output worsening since 5 days

History of presenting illness:
Patient was apparently assymptomatic 20 years back , she developed pedal edema and decreased urine output ,shortness of breath   since 1 year  
-  Edema B/l pitting type extending from ankle to below knee 
  -Decreased urine output  and high coloured urine since 1month.
   -Pt had vomitings which is non-projectile ,non-bilious with food as contents since 1 month on and off
  -Pt had loose stools   On and off since 1 month

-k/c/o DM since 20 years on TAB.GLIMI2  8am-- 8pm 
Since 1 year due to hypoglycemic seizure episode  she is taking  TAB.GLIMI-M2  1 tab at 2pm 
Not a k/c/o HTN,ASTHMA , EPILEPSY ,TB

IN 2002:
Pt developed pain abdomen for which pt was admitted in hospital and undergone TOTAL HYSTERECTOMY ?FIBROIDS .

IN 2009:
Pt developed chest pain (RT sided)  for which he was admitted in hospital and  she was taken for primary PTCA.
On angiogram it is showing -double vessel disease (RCA+ LAD)

IN 2016:
She  had another episode  of chest pain she was taken to hospital  and  DES to LAD  was done.

-From 2009  she had intermittent episodes of pain abdomen in hypogastric region which relived on medication PAN 40 MG.

2021 :
Pt had hypoglycemic seizure  episode (sweating,slurred speech, deviation of mouth )after her regular GLIMI-M2   at 5:30 am her GRBS was 35mg/dl for which she was taken to private hospital then her dose changed from 8AM --8PM to.  2pm   

 Since. 1 year pt c/o pedal edema on&off , SOB on &off ,decreased urine output on &off since 1month .Pt  symptoms got aggravated for pt was taken to an private hospital and was kept on IV OROFER INJECTION due to anemia for which pt developed periorbital oedema as side effect.

General examination:
Patient is conscious, coherent, co-operative, oriented to time, place and person 
No Icterus, Cyanosis, Lymphadenopathy,
Pallor ++
B/l pitting type  Edema +

Vitals:
Bp: 100/70mmHg 
PR: 96bpm
SpO2: 98%@RA
Temperature:98. 6°F
GRBS:  102 mg/dl
CVS: S1, S2 +
RS: BAE +, NVBS heard
P/A:SOFT NON TENDER,BOWEL SOUNDS +
CNS: NAD

B/L pedal edema 
INVESTIGATIONS:

ON 27/5/22

Chest xray -Pa view

ECG:
USG ABDOMEN :
Diagnosis:
ANEMIA SECONDARY TO CHRONIC KIDNEY DISEASE 
? DIABETIC NEPHROPATHY
S/P:OLD  CAD -PTCA +DES TO LAD (2009 ,2016) 
 WITH TYPE -2 DM SINCE 20 YEARS 

Treatment on 27/5/22:
1)FLUID RESTRICTION <2LITRE /DA
2)SALT RESTRICTION <2G/DAY
3)INJ.LASIX 40MG IV/BD
         8AM -----4PM------×
4)INJ.PAN 40 MG IV/OD
         8AM ------------×
5)INJ.HAI S/C. TID
       8AM -------1PM------8PM
6)GRBS CHARTING 7POINT PROFILE 
     7AM------1PM--------7PM
     9AM-------3PM-------9PM
7)TAB.ECOSPRIN Av PO/OD
       X--------2PM-------×
8)TAB.OROFER -XT PO/OD
        8AM-------×-------×
9)TAB.SHELCAL CT PO/OD 
          X--------2PM------×

27/8/22 -28/5/22
7POINT PROFILE -GRBS 
8PM -177MG/DL (INJ.HAI 6U GIVEN )
10PM- 102 MG/DL 
2AM- 71MG /DL
7AM -90MG/DL
9AM -


Popular posts from this blog

A 42 Year old woman with multiple health events since birth

Image
Hi everyone, this is chandan  4th year mbbs student and i was given a case to learn better in approaching a case. Case given to me is in the link given below:👇 https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 Case: It was a 42yr old female with Chief complaints::: 1.Loss of coordination ,numbness on the left side. 2.Breathing problems. 3.Salt cravings. 4.Swelling. 5.Poor stress response Reasons for the problems: 1.Loss of coordination and numbness on the left side indicating like left sided hemiplegia. -causes can be Brain infections,Brain tumors,Genetic abnormalities. -she also suffered with very long duration of migraine and severe headache;hemiplegia associated with migraine can be hemiplegic migraine which is a genetic abnormality due to mutation of genes like ATP1A2,SCN1A. -she has low vitamin B12 levels which causes demyelination of neurons ,may be a cause for loss of coordination and spinnimg movements. 2.Breathing problem
Read more

1601006011 long case

Image
Hall ticket no.1601006011 This  is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome I've 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.  Case: A 55year old male toddy climber by occupation came with complaints of pain abdomen and fever. Following is my analysis of this patient's problem
Read more

1601006011 SHORT CASE

Image
Hall ticket no.1601006011 SHORT CASE. FINAL EXAM SHORT CASE 35 year old male patient,  RESIDENT - ramchandrapuram, OCCUPATION- works as a daily wage labourer, a chronic smoker (1 pack of beedi every 2 days) and chronic alcoholic (90ml daily) since 20 years presented with a  3 month history of painless papules with erythema that started initially over the face then gradually extended to upper limb, low limbs and trunk  ~Patient got topical cream, soap and some oral drugs from nearby medical shop  ~He used them for 2 months, few lesions regressed but few persisted on nose, ear lobe, hands, legs and trunk. ~14 days ago patient developed blackish skin discolouration over hands and feet with skin peeling, cracking, ulcer formation associated with burning sensation and erythema all over the body. ~No new lesions were noted  Since 4 days patient developed continuous high grade fever associated with chills and rigors. Loss of appetite  There is no history of similar complaints in the past  EXA
Read more