CHRONIC KIDNEY DISEASE
A 50 year old female patient with loin pain and pedal edema
January 19, 2023
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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.
CHEIF COMPLAINT:
A 50 year old female patient who is resident of athmakur mandal suryapet district and home maker came to the casuality with cheif complaint of loin pain since 1 year and pedal edema since 1 month.
HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 1 year back then she developed pain in the loin region since 1 year, which was gradually progressive,non radiating, has no relieving and aggravating factors. Then she developed bilateral pedal edema which is pitting type since 1 month
Pedal edema upto feet (mild pedal edema)
No history of fever
Facial puffiness and decreased urine output can be seen.
HISTORY OF PAST ILLNESS:
N/k/c/o diabetes, Asthma, epilepsy ,hypertension
Usage of NSAIDS more than 1 year ,denovo hypertension due to usage of NSAIDS.
PERSONAL HISTORY:
Appetite normal
Sleep is inadequate
Diet is mixed
Bowel movements regular
Bladder movements normal
No known allergy
FAMILY HISTORY:
No known relevant family history.
GENERAL EXAMINATION:
Patient is conscious, coherent , co-operative and well oriented to place, person and time.
Physical examination:
Pallor : present
No Icterus, cyanosis lymphadenopathy edema clubbing,no Malnutrition, no Dehydration.
(patient fell from an auto hence this is the injury caused due to it)Vitals:
Vitals:
Temperature :98 F
Pulse rate: 92 beats per minute
Respiratory rate :16 cpm
Blood pressure: 160/100mmhg
SYSTEMIC EXAMINATION:
Cardiovascular system:
Inspection:
elliptical and bilateral symmetrical chest,
No visible engorged veins, scars and sinuses on the chest
Palpation:
No Thrills ,cardiac murmurs
Cardiac sounds s1 s2 heard.
Apex beat palpable at 5 th intercostal space medial to mid clavicular line .
Auscultation:
No cardiac murmurs
Cardiac rate 100 beats per minute
Respiratory system:
Inspection:
bilateral symmetrical,
Trachea is central,
No scars , sinuses or visible pulsations,
Suprasternal and supra clavicular notching is present.
Palpation :
all inspectory findings are confirmed.
No local raise of temperature.
No tenderness,dysponea wheezing
Auscultation:
Breath sounds vesicular
Bilateral Air entry present
Abdominal examination:
Inspection:
Shape of abdomen :obese
Umbilicus : central and inverted No scars are visible
Free fluid: no organomegaly.
No sinuses
Palpation:
Liver not palpable
Spleen not palpable
Bowel movements regular
No tenderness palpable masses
Percussion:
Shifting dullness is positive
Auscultation:
Bowel sounds are heard
Central nervous system:
Patient is conscious and speech is normal.
No neck stiffness
No meningial signs,
Sensory system normal,
Motor system normal .
Oral examination:
Tongue pallor can be seen
Generalised attrition
Calculus present
Plaque present
Teeth rotation
Spacings present in between the teeth(diastema)
IMPRESSION: NORMOCYTC NORMOCHROMIC ANEMIA
Chest X-ray:
2D echo:
RFT:
RBS:
HEMOGLOBIN:
Impression: decreased hemoglobin percent
BLOOD GROUP:
8
ECG :
PROVISIONAL DIAGNOSIS:
CHRONIC KIDNEY DISEASE
ANAEMIA
TREATMENT:
Inj furosemide-40mg/IV/TID
Tab Sodium carbonate (nodosis)-500mgPo/TID
Tab NICARDIA-10mgPo/TID
Tab shelcal--500mgPo/OD
Inj PAN-40mg IV/OD
Cap biod-3po/OD
Inj erythropoietin-4000IUSC
Inj iron sucrose-100mg/IV/100mlweekly once
Dialysis
General points on ckd:
It is a slow insidious irreversible deteoration of the renal functions resulting in uremia and excretory hematological neurological and endocrinal Abnormalities.
Albuminuria and decreased GFR are the hallmarks
