MEDICINE CASE DISCUSSION
65 year old female with Chronic renal failure .
March 30, 2022
P.Manasa
9th semester
Roll no:- 102
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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.
Daily Routine:-
She wakes morning at 7AM .At7:30 AM drinking honey and lemon water then watching TV and doing daily work.Having lunch (rice with curry) and At 8pm dinner( chapathis).
CASE
A 65 year old female homemaker , resident of miryalaguda came to the OPD yesterday morning with the
Cheif complaints
Swelling of hands and feet since 15 days
Swelling of the face since 15 days
Easy fatigability since 15days
Shortness of breath since 5 days (grade 4)
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 15 days back then she developed pain and swelling in leg which was sudden in onset , gradually progressive which was aggravated on exercise and relevied by taking rest.
* she had swelling of hands and feet since 13days
* Facial puffiness since 5days
* c/o joint pains since 15 days , she is unable to walk and work for 4days.
No history cough , chest pain ,
No history of fever, burning micturation ,hematuria.
Event time line:
*3 months ago , she started consuming protein powder for weight loss , she used to consume only one meal a day that is in the afternoon and used to drink protein powder both morning and evening.
*2 months ago : H/O fall due to sudden loss of balance breaking her left wrist for which she went to a local RMP and was suggested an Ayurvedic slab for the left wrist !
*15 days ago : she went for the removal of the Ayurvedic slab .
PAST HISTORY
She is known case of diabetes and hypertension for the past 15years for which she is under regular medication.
On Telma H 40mg and on Azulix 1 MF ( glimiperide + metformin)
*2 months ago : H/O fall due to sudden loss of balance breaking her left wrist for which she went to a local RMP and was suggested an Ayurvedic slab for the left wrist !
* Not a known case of thyroid ,TB , epilepsy, CVD etc.
* History of Right eye cataract surgery two years back .
* No history of blood transfusions
Menstrual history
Age of menarche - 13yrs
H/o Tubectomized 22yrs ago
PERSONAL HISTORY
Patient is conscious, coherent and coperative examined under well lit and good ventilaton.
well built and moderately nourished
Vitals :
Temperature: afebrile (98.3 degrees F)
Pulse rate: 91bpm
Respiratory rate :18cpm
Blood pressure : 140/90 (as of today morning)
Spo2 -99% in room air
SYSTEMIC EXAMINATION :
RBS
Blood urea
HBsAg
Serum iron
2D echo
Provisional Diagnosis : ?CHRONIC RENAL FAILURE ?diabetic nephropathy ?uremic encephalopathy
Treatment:
On 29.03.22
1) TAB . Lasix 40 mg PO/BD
2) TAB. Nodosis 500 mg PO/BD
3) TAB. Shelcal CT 500 mg PO / OD
4) TAB. Orofer XT 1 tab PO /OD
5) TAB. PAN 40 mg PO/OD
6) INJ. Erythropoietin 4000 IU SC. Weekly once
7) TAB. Nicardia 20 MG PO/TID
On 30.03.22
1) TAB . Lasix 40 mg PO/BD
2) TAB. Nodosis 500 mg PO/BD
3) TAB. Shelcal CT 500 mg PO / OD
4) TAB. Orofer XT 1 tab PO /OD
5) TAB. PAN 40 mg PO/OD
7) TAB. Nicardia 20 MG PO/TID
On 31.03.22
1) TAB . Lasix 40 mg PO/BD
2) TAB. Nodosis 500 mg PO/BD
3) TAB. Shelcal CT 500 mg PO / OD
4) TAB. Orofer XT 1 tab PO /OD
5) TAB. PAN 40 mg PO/OD
7) TAB. Nicardia 20 MG PO/TID
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