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
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