Case history- 2

 August 23, 2021

"This is an online E- log book to discuss our patient's de- identified health data shared after taking his/ her guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts with an aim to solve those patients clincal 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. "

Date of admission: 20/8/21

A 46 year old female patient agriculturer by occupation presented to the OPD with chief complaint of swelling in the right side of the leg. 

History of present illness:

Patient was apparently asymptomatic 4 months back. 

In the month of June (16/8/21) , patient noticed swelling of both the legs and was diagnosed with CKD, suggested on dialysis. Patient has undergone total 11 dialysis till 6/8/21

Patient presented to the OPD 3 days back i.e ( 20/8/21) with swelling in the right side of the leg. 

There is history of pain associated with swelling

Past history:

No history of surgeries in the past. 

Patient is a known case of diabetes since 3 years. 

No history of asthma, epilepsy. 

Personal history:

Appetite- normal

Sleep-adequate

Addictions- no addictions

Family history:

No history of thyroid disorder, asthma, CAD, diabetes, hypertension in the family. 

General examination: 

Patient is conscious, coherent and cooperative

No pallor, no clubbing

Paedal edema is present

Vitals: 

Temperature- afebrile

Pulse rate-84 bpm

BP- 90/60 mm Hg

Systemic examination:

CARDIOVASCULAR SYSTEM

S1 S2 heard. 

No thrills. 

RESPIRATORY SYSTEM

Postion of trachea- central

Breath sounds- vesicular

PER ABDOMEN:

Shape- scaphoid 

Tenderness- no

Hernial orifices- normal

CENTRAL NERVOUS SYSTEM:

Level  of consciousness- conscious

Speech- normal

Motor and sensory system- normal

Investigations:

RFT:

Urea: # 45 mg/dl

Creatinine: # 2.3 mg/dl

Uric acid : # 7.9 mg/dl

Calcium: 10 mg/dl

Phosphorus : 3.7 mg/dl

Sodium:# 132 mEq/L

Potassium: # 3.4 mEq/L

Chloride: 105 mEq/L



Provisional diagnosis:

CKD with idiopathic deep vein thrombosis

Treatment:

1. T. LASIX 20 mg

2. T. NODOSIS 500 mg

3. T. ODOFER

4. SHELCAL

5. Inj. Erythropoietin 4000IU/SC/Weekly twice

6. Inj. Iron sucrose / amp in 50ml

7. Inj. HAI S/C

8. Fluid restriction< 1.5 L/day

9. Salt restriction< 4 gm/day


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