59 K. Rithika Vasantha

E-LOG GENERAL MEDICINE
Hi, This is Rithika, a third semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them. 


A 45 YR OLD WOMAN WITH CKD ON MHD

Chief complaints:
             
                 A 45 yr old female, P2L2, hailing from Velimimedu, agricultural worker by occupation, came with the  hief complaints of :

• SOB at rest, since 2 mnths
• Pedal edema, since 2 mnths
• Nausea, since 2 mnths
• Blurring of vision
• Increased thirst
• Loss of appetite

HOPI:

• Apparently patient was asymptomatic 2 months back. 
• Later, she developed SOB while doing small, regular household chores, which later got progressed to SOB at rest. 
• Simultaneously, she also developed facial edema and pedal edema. 
• She also had severe nauseating feeling with slight rise of temperature. 
• After a month of suffering, she visited a doctor in hyderabad, where she was suggested dialysis as she was diagnosed with CKD. 
• After almost 10 dialysis rounds, she came to our hospital to continue the treatment. 
• She has no history of headache, body pains. 

Personal regular timeline of the patient before 2 months ( asymptomatic phase) :

        Patient used to wake up at 5:30 am on the morning, followed by breakfast and then rushing to her agriculture work by 9am.
        She then used to take lunch break for an hour around 1-2pm under a shade and then continue to work till 5pm.
        She then comes back from work, has a little social and family time and then has her last meal by 9pm and goes to sleep. 

Personal regular timeline since 2 months ( symptomatic phase) :

         Since she developed pedal edema, SOB and nausea..... She didn't feel like going to work , due to which she remained at home since then. 
         Now with regular dialysis and hospital admissions, she doesn't get enough time with family and friends and also feels vexed up with all the hustle going around her. 

History of past illness:

• She has a history of DM since 10 yrs for which she has been taking insulin. 
• She also has a history of HTN since 1 year... for which she is on medication. 
• She has no history of epilepsy, TB, cancer, asthma, blood transfusion. 

Family history:

• Nil significant

Personal history:

• Has loss of appetite
• Follows mixed diet
• Bladder habits normal and regular
• Bowel habits - constipated
• No addictions

PHYSICAL EXAMINATION:

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy

Vitals:

• Temp. - 98.6°F
• PR - 98bpm
• RR - 18 cycles/min
• BP - 110/80 mmHg
• SpO2 - 98%

SYSTEMIC EXAMINATION:

• CVS - S1, S2 heard
• RS - BAE +
• Abdomen - No tenderness, no palpable mass, liver and spleen not palpable, no bruits present
• CNS - Conscious, normal speech, no signs of meningeal irritation

INVESTIGATIONS:


TREATMENT:
 
• MHD
• Lasix 40mg
• Nodosis 500 mg
• Shelcal 500 mg
• Orofer
• Nicardia
• Mixtard insulin
• Inj. Iron sucrose weekly once

Progress of recovery after treatment:

• Now, there is no facial edema, pedal edema. 
• Nausea , blurring of vision is still present


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