1801006070 - LONG CASE
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the 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 competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
29 year old female customer service executive came to the hospital with complaints of swelling of both legs and both eyes since 3 days.
HISTORY OF PRESENT ILLNESS
In 2017 she had generalised body aches and joint pains involving multiple large joints of which elbow and knee joints troubled her associated with generalised body aches .
she even noticed hair loss without scarring and oral ulcers . Later , she was diagnosed with autoimmune disorder and initiated on hydroxychloroquine , azathioprine , wysolone .
She reported that her joint pains and hair loss were not improving with above medication . She had multiple hospital visits and admissions for joint pains and body aches which bothers her from doing her activities .
Two months back she had pedal edema , sudden onset of shortness of breath initially on exertion then she was diagnosed with hypertensive emergency admitted and discharged with antihypertensives . Patient stopped AZA as advised by doctor except antihypertensive . since yesterday she had shortness of breath initially on exertion which rapidly progressed to sob at rest
No small joint pains no colour change /paraesthesia so fingers on exposure to cold
PAST HISTORY
Known case of SLE and is on
Tab orofer xt po/od 8am
Tab shelcal 500mg po/od
Tab sodium bicarbonate 500mg po/bd
Tab nicardia 20mg po/tid
Probiotics
She’s not a known case of diabetes, CAD, asthma, tuberculosis.
PERSONAL HISTORY
Her day starts at 7 AM . She used to get ready for work and went to office at 8 AM . have breakfast at office at around 10 am . Her work was more of attending client calls with 1-2 breaks in between till 6 PM.Sleeps at 11 pm . Since one month , she had quit her job due to regular dialysis.
Appetite :lost
Sleep : Adequate
Bowel movements : Reduced
Micturition : Decreased urine output
No addictions
MENSTRUAL HISTORY
Age of menarche:12 years.
Menstrual cycles :Her Menstrual cycles were irregular since 2 months.
Her last Menstrual period was Dec 25th 2022
Obstetric history:- para 2 live 1
GENERAL EXAMINATION
Pallor: present
Flat nails
Non-scarring alopecia
Hyperpigmented discoid rashes on face
Periaural black discolouration of oral mucosa and palate
Mild pedal edema
No icterus, cyanosis, lymphadenopathy
Vitals:
Temperature: 98.2 F
Pulse rate: 131bpm
Respiratory rate: 24/min
BP: 180/110mmhg
Spo2: 98%
GRBS: 98mg/dl
S1 ,S2 present
No murmurs
RESPIRATORY SYSTEM
Bilateral air entry present
Normal vesicular breath sounds heard
No dyspnoea and no wheeze
PER ABDOMEN
Shape of abdomen: scaphoid
Tenderness present around umbilicus
Liver and spleen are not palpable
CNS
Patient is conscious
Speech: normal
Cranial nerves: normal
Motor and sensory system: normal
Glassgow coma scale: E4 V5 M6
INVESTIGATIONS
15.03.2023
Blood urea -79 mg/dl (N=12 to 42 mg/dl)
Serum creatinine-4mg/dl(N0.6 to 1.1)
Serum electrolytes-
Na :141mEq/L(N-136 to 145)
K:3.5mEq/L(N:3.5 to 5.1)
Cl:102mEq/L(N=98 to 107)
Ionized ca+2:1.01mmol/L.
14.02.2023
HEMOGRAM:
Hb 8.5gm/dl.
Total count:12000 cell /cumm
Neutrophils:83 %
Lymphocytes:11%
Pcv:24.3 volume %
Platelets :l.lL / cumm.
Impression :Normocytic normochromic anemia with neutrophilic lymphocytes and thrombocytopenia.
Renal function test:
Blood Urea:157mg/dl
Serum Creatinine :6.9 mg/dl.
DIAGNOSIS
Chronic kidney disease
TREATMENT
Tab Nicardia 30mg,po/tid
Tab lasix 40mg , po/bd .
Tab wysolone,po/bd.
Tab azathioprine 50 mg po/ od
Tab hydroxychloroquine 200mg po/od.
Tab Met xL 25 mg ,po/od.
Tab nodosis 500mg po/od.
Tablet shelcal 500mg po/od
Tab orofer xt po/od
Tab Pan 40mg po/od.
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