38 year old female with CKD

- January 10, 2022

Name:G.Sai Vidya , 9th semester

Roll .no : 36

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 inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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 diagnosis and treatment plan.

A 38 year old female shopkeeper from miryalaguda came for regular session of hemodialysis.

Chief complaints:

She came for her regular hemodialysis

She has Shortness of breath since three days

History of presenting illness:

Patient was apparently asymptomatic 4 months back then she noticed :

swelling of her lower limbs,

she also had few episodes of vomiting immediately after having food

she was unable to flex her legs and she found difficult in squatting

she used to feel drowsy and sleeps for prolonged period .But she neglected all those symptoms .

2months ago suddenly she developed shortness of breath for that she went to a nearby government hospital they prescribed her two medications after which she was feeling fine .
Later on the next day Blood test was done which suggested that her hemoglobin level was very low and the concerned doctor advised her for bloodtransfusion.
So ,she presented to our hospital ,in our hospital after performing thorough examination and investigations , she was diagnosed with CKD and she had severe anemia(3-4%)
AUB and severe anemia:

Past history:

Patient gives history of pcos ,for which she used homeopathy medications
She's a known case of hypertension since one month
There's a typical history of eczematous rash ,she developed this rash 4 months back for which she used homeopathy treatment but the rash didn't subside
No history of DM,Thyroid,Asthma,epilepsy

Personal history:

Diet: mixed

appetite: decreased

Bowel movements :regular

Bladder movements: decreased frequency of micturition

Sleep: not adequate (due to : shortness of breath)

Addictions:none

Her daily routine when she was absolutely normal :

-Wakes up at about 6am

-she does all her household work like every other person.

-at 9:00 a.m. she goes to her shop and stays there until 2 p.m. Comes back home ,she’ll have her lunch and she takes a nap then she goes back to shop ,comes back home she’ll have her dinner and she goes to bed at around 9:00 p.m. this was her daily routine when she had no health complaints.

Family history:

Insignificant

Treatment history:

She used homeopathy medication for PCOS and eczematous Rash

her PCOS subsided but the rash did not subside

Allergic history:

She is allergic to diclofenac sodium

(Citrizine and betnisol was given to control it)

General examination :

patient is conscious, coherent ,cooperative and well oriented to time place and person

Moderately built and moderately nourished

no Pallor,icterus, Cyanosis,Clubbing, Lymphadenopathy