A 30 YR FEMALE PATIENT WITH CHRONIC KIDNEY DISEASE— MAINTENANCE ON HEMODIALYSIS

 This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Hyndavi Konakanchi, 9th semester 

Hall ticket number : 1701006085 - SHORT CASE 

June 10, 2022

A CASE DISCUSSION 30 YR OLD FEMALE WITH CHRONIC KIDNEY DISEASE — MAINTENANCE ON HEMODIALYSIS 

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.

Following is the view of my case : 

30 years old female, who is  HOUSEWIFE by occupation resident of nalgonda 

 came to the opd with the CHEIF COMPLAINTS: 

* Abdominal pain since 7 days

* shortness of  breath since 4 days

* pedal edema    since  4 days

* facial puffiness  since 4 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 12 months back then she developed;

 * Abdominal pain : pain since 7 days which started suddenly and burning type of pain In epigastric region No aggravating and reliving factors

* Breathlessness:

shortness of breathe since  4 days  which is of grade 4 and associated with profuse sweating.

SOB: insidious in onset gradually progressed to grade 4 not associated with change in position no aggravating and relieving factors 

* Pedal edema:

She complaints of pedal edema   since 4 days   which is of pitting type. She had similar edema episodes before this one month which were resolving and reappearing and this time it is not resolved for 1 month. 

* She also developed facial puffiness 

TIME LINE OF EVENTS :

* No history of  FATIGUE 

* No history of COUGH, HAEMOPTYSIS

 * No history of DYSPHAGIA, HOARSENESS OF VOICE 

*  No history of HIGH ARCHED PALATE, CHEST DEFORMITY 

* No history of RECURRENT RESPIRATORY TRACT INFECTIONS, FEVER, SORE THROAT, CLUBBING, SPLINTER HAEMORRHAGE 

 * No history of FEVER, JOINT PAINS 

PAST HISTORY:

* She is diagnosed as Gestational HYPERTENSION 12 years back for first pregnancy (after 4th child she discontinued use of  anti hypertensive drugs)

* She is a not a known case of diabetes, asthma, epilepsy, hyperthyroidism, COPD 

* No history of blood transfusion 

* No history of allergy 

MARTIAL HISTORY:

* Age of menarche 12 year 

* Age of marriage 18 years 

* It is a nonconsanguinous marriage 

* She has 4 children

— ( in 2011 first child(girl )-  normal vaginal delivery  -diagnosed as HYPERTENSION 

— In 2012 second child(girl)- normal vaginal delivery 

—   In 2014 third child(girl) - normal vaginal delivery 

— In 2015 fourth child(girl)- normal vaginal delivery  -she also had episode of Dyspnea of grade 3     (not get attention to symptoms)

FAMILY HISTORY:

father and mother are known case of HYPERTENSION since 6years

PERSONAL HISTORY:

DEIT: mixed

APPETITE: loss of appetite 

BOWEL :normal 

BLADDER: DECREASED URINE OUTPUT 

SLEEP: INadequate 

ADDICTIONS: no addictions

GENERAL EXAMINATION:

A 30 year old patient, who is moderately built and well nourished is CONSCIOUS, COHERENT, COOPERATIVE, AND COMFORTABLY LYING ON BED, well oriented to TIME, PLACE AND PERSON. 

THERE IS PALLOR 

NO icterus 

NO cyanosis 

No koilonychias

No generalized lymphadenopathy and 

No pedal edema 

Vitals:

 Temperature: a febrile

 Pulse: 92/ min

 Blood pressure: 150/90 mmHg 

 Respiratory rate : 34 cpm

SYSTEMIC EXAMINATION:

RESPIRATORY  SYSTEM:

Patient examined in sitting position

INSPECTION 

oral cavity- Normal ,nose- normal ,pharynx-normal 

Shape of chest - normal

Chest movements : bilaterally symmetrically reduced

Trachea is central in position & Nipples are in 4th Intercoastal space

APEX IMPULSE VISIBLE IN 6TH INTERCOASTAL SPACE 

PALPATION 

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 6 thICS, 

Chest movements bilaterally symmetrical reduced

Tactile and vocal fremitus REDUCED on both sides  in infra axillary and infra scapular region

PERCUSSION

DULL IN BOTH SIDES in infra axillary and infra scapular region

AUSCULTATION 

DECREASED ON BOTH SIDE in infra axillary and infra scapular region 

BRONCHIAL sounds are heared -REDUCED 

CARDIOVASCULAR SYSTEM :

JVP -raised

Visible pulsations: absent 

Apical impulse : shifted downward and laterally 6th intercostal space

Thrills -absent 

S1, S2 - heart sounds MUFFLED 

PERICARDIAL RUB-PRESENT 

ABDOMEN EXAMINATION:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :absent

Skin or surface of the abdomen : normal 

PALPATION

Liver is not palpable 

PERCUSSION- dull

AUSCULTATION :bowel sounds heard

 INVESTIGATIONS :

HIV TEST 

HBSAG

CBP

BLOOD GROUPING 

RFT

SERUM IRON 

ECG

BACTERIAL CULTURE 

X RAY :

2D ECHO

PLUERAL TAP

DIAGNOSIS:

A CASE OF KNOWN HYPERTENSION 

A CASE OF  CHRONIC KIDNEY DISEASE ON MAINTENANCE OF HEMODIALYSIS 

HEART FAILURE MAY  BE SECONDARY TO CKD 

PLEURAL EFFUSION  & PERICARDIAL EFFUSION  secondary to HF AND CKD ( fluid overload)

TREATMENT:

INJ. MONOCEF 1gm/IV/BD

INJ. METROGYL 100ml/IV/TID

INJ PAN 40mg/IV/OD

INJ. ZOFER 4mg/iv/SOS

TAB. LASIX 40mg/PO/BD

TAB. NICORANDIL 20mg/PO/TID

INJ. BUSOCOPAN /iv/stat

 Add on

TAB. OROFER PO/BD

TAB. NODOSIS 500mg/PO/TID

INJ.EPO 4000 ml/ weekly 

TAB. SHELLCAL/PO/BD 

* DIALYSIS (HD)

INJ.KCL 2AMP IN 500 ml NS over 5min