A 40 YR FEMALE WITH CKD ON MHD
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Hyndavi Konakanchi, Intern
23/12/22
A CASE DISCUSSION 40/F CASE WITH CKD ON MHD
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 :
A 40 yr old female who is apparently asymptomatic 4 yrs back and then one fine day when she was doing her work in their shop; she developed giddiness and went to local RMP in cheruvugattu ; there she was diagnosed to have blood pressure of around 160-170 ( diagnosed for the first time as hypertension)
So from then she used medication for 2 months — but there is no regular BP checkups in between
And again on fine day when she was doing work in their shop, Developed giddiness again ; this time she went to a hospital in Nalgonda— there she was diagnosed to have kidney failure ; he advised some medications — she began using them and continued till now
On 13/12/22 ; when she was doing household activities,,Developed giddiness , B/L pedal oedema,SOB grade 4 , vomiting even after eating anything , she went to HYDERABAD YASHODA HOSPITAL — There doctors advised dialysis
1st dialysis was done on 14/12/22
2nd dialysis was done on 16/12/22 and discharged; doctors advised weekly 3 times dialysis, which can be done anywhere on day care basis, ,So came to our hospital for dialysis as it is near to their home in cheruvugattu
COMING TO HER DAILY ROUTINE: She is a shopkeeper by occupation
She wakes up at 5 am in the morning — freshen up & does house hold activities and go to work
By 8 am in the morning she goes to their shop along with lunch box
She returns home by around 6 pm in the evening
She does some household activities and freshen up and eat dinner and sleep by 10 pm
But from 2 yrs she stopped going to work as she is unable to do work in the shop But did household work slowly in the day
She eats rice and curry in the morning, afternoon, night ( 3 times a day )
But after she was diagnosed to have kidney failure in nalgonda ; she started to consume food which is less salty,spicy,oily and decreased water intake
MEDICAL HISTORY:
* She is under medication ( MET XL - metoprolol) from 4 years
DIET : Mixed
APPETITE : Normal
SLEEP : Normal
BOWEL AND BLADDER HABITS : Normal
ADDICTIONS: No
GENERAL EXAMINATION
* Patient is concious coherent and coperative, well oriented to time palce and person
VITALS
Blood pressure : 180/100 mm hg
Pulse Rate : 92 bpm
Temperature : 98.6 degrees F
SPO2 : 98 @ RA
GRBS : 102
* NO ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY
RESPIRATORY SYSTEM EXAMINATION :-
Inspection-
CNS EXAMINATION :-
* No focal neurological deficits
* Higher motor functions are normal
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