FINAL PRACTiCAL LONG CASE

Final practical long case

Imama Muhmeen

Roll no 163

Hall tcket no. 1701006060

Mbbs 9th sem

9/6/22  

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect6current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

Your valuable inputs on comment box is welcome

 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan 

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever

ACKNOWLEDGEMENTS

1)Few of the Images are taken from the following Elog

https://csravanthi.blogspot.com/2022/06/final-practical-examinationshort-case.html

CASE OF A 64Y/O FEMALE PATIENT WITH CRF 

Patient is a 64 yr old female came to the OPD with chief complaints of 

Lower back pain since 1 week 

Decreased urine output since 1 week 

Body pains , Shortness of breath on slightest of exertion

On and off fever associated with burning micturation

She was diagnosed as having renal dysfuntion about 2yrs ago in another hospital. (Details not clear)

HISTORY OF PRESENTING ILLNESS

• Patient was apparently asymptomatic 1 week back then she developed lower back pain, insidious in onest, gradually progressive which is of dragging type and radiating to both legs 

• Decreased urine output since 1 week and 1 day back urine output has completely stopped 

• 2 yrs ago she was diagnosed as renal failure

•Her first dialysis was 2 days back evening at 4 pm 

ASSOCIATED SYMPTOM ; Burning micturition since 1 week with on and off type of fever

PAST HISTORY 

 •NSAID ABUSE SINCE 8 YEA4S

•7years back had trauma of distal phalanges of left hand and lost them 

 》OBSTETRIC HISTORY

• she gave birth to 5 children through normal vaginal delivery

• Patient underwent hysterectomy 3 yrs back for a prolapsed uterus

PERSONAL HISTORY

Diet - mixed

• Loss of appetite

• sleep - adequate

• Bowel movements -regular

• Bladder- micturition reduced and burning

• No allergies 

FAMILY HISTORY

Not significant

GENERAL EXAMINATION

Patient is examined with informed consent

Patient is conscious and coherent , co-operative , oriented to time, place ,person.

Moderately built and moderately nourished

Pallor : present

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

VITALS( At the time of admission)

Temperature- 

Pulse rate -90

Respiratory rate - 18 cpm 

Blood pressure- 110/80

Spo2 -98 

GRBS- 111mg % 

SYSTEMIC EXAMINATION

CVS S1 S2 HEARD ,No murmurs 

RS: BAE +

ABDOMINAL EXAMINATION :

Bowel sounds heard

Soft tenderness at lowel abdomen

 CNS :

Higher mental functions are normal 

Sensory and motor examinations are normal

No signs of meningeal irritation

Cps

INVESTIGATIONS

2 dayz later on admission

 PROVISIONAL DIAGNOSIS

CHRONIC KIDNEY DISEASE causing Renal Osteodystrophy

Patient was advised Maintainance Hemodialysis 3 times a week

Post dialysis state:

He got 1st round of dialysis on 7/6 through central line iv

The process took 4 hours. 

Afterwards, the patient did not complain of any giddiness, weakness, lightheadedness, fever or pain

BP measured was found to be 125/80.

He is scheduled for next round of dialysis in 2 days.

D/d :; CRF SECONDARY TO ANALGESIC NEPHROPATHY