General medicine case-icu bed no.1
Date of admission:-12/09/2023
Case scenario:
A 29 yr old female came to the opd with the chief complaints of shortness of breath since 3 days
History of present illness
- Patient was apparently asymptomatic 5 years ago then she noticed loss of hair and patches over her head,which is associated with joint pains and uclers
Then she developed pedal edema and renal biopsy was done and diagnosed with lupus nephritis and was on conservative management.
Patient was initiated on hemodialysis since February 2023 and is on MHD(maintenance hemodialysis).
Presently Patient presented with shortness of breath since 3 days which was sudden in onset and gradually progressive. No aggravating and relieving factors
Past history:
K/c/o hypertension since February and is on medication :
Nicardia 10mg po/tid
Arkamine 0.1mg po/tid
K/C/O seizures : Patient had one episode of involuntary movements initially started left-hand followed by total body with impaired consciousness no tongue bite no involuntary maturation or defecation an year ago.
N/K/C/O DM, CVA,CAD,TB
Personal history:
Diet - mixed
Appatite-loss of appetite
Sleep- adequate
Bowel and bladder - regular
No Addictions
Daily rotinue:
Previously before February 2023 patient used to wake up early by 7am and had breakfast and go to work as customer service care member talked to clients and returned home by 5pm. Cooked for the family members had dinner by 8pm and slept by 10pm.
Daily rotinue after 2023 February. Patient wakes up at 9am and freshens up. Cooks breakfast and eats by 10pm . Takes the medication and takes rest then by 1pm she takes her lunch then rests and sleeps. Has dinner by 9pm and sleeps around 10.30pm.
Family history: not signifiant
General examination :
Patient is conscious coherent and cooperative. Moderately built and nourished.
Pallor - present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy-absent
Edema- present
Vitals:
BP:130/80
PR: 82
RR:17
TEMPERATURE: 97.3 F
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM
•S1, S2 heard
RESPIRATORY SYSTEM:
•NVBS heard
•Position of trachea - central
•Breath sounds - vesicular
ABDOMEN
•Shape - schaphoid
•No Tenderness
•No palpable mass
-No fluid present.
-No palpable liver or spleen
CENTRAL NERVOUS SYSTEM:
•Intact
•No focal defect
•No abnormality detected
Provisional diagnosis :
Lupus nephritis on Maintainance haemodialysis with Pulmonary edema
Investigations :
Final diagnosis:ACUTE CARDIOGENIC PULMONARY EDEMA WITH STAGE 4 CKD SECONDARY TO LUPUS NEPHRITIS WITH K/C/O HTN SINCE 7 months
Treatment:
1.Fluid restriction <5L per day
2.Salt restriction <2gms per day
3.T.Nicardia 30mg po/bd
4. Tab predinisolone 5mg po/bd
5. Tab arkamime 0.1mg po/tid
6.Metaprolol 50mg po/od
7.Sildenafil 15mg po/od
8.Tab Shelcal-ct po/od
9.T NODOSIS 500mg po/bd
10. Monitor vitals 4th hourly
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This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 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 The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. CO
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. A 29 year old female who is a known case of SLE , customer service executor by occupation, resident of akkinepalli came to OPD with cheif complaints : swelling of both legs since 3 days swelling around eyes since 3 days . * History of presenting illness: - Pateint was apparently asymptomatic 6 years ago, then she developed oral ulcers and rash on face and joint pains , hair loss without scaring for which she went to a hospital and diagnosed with Systemic lupus erythematosis (2017). She was on Hydrochloroquine 200 ,wysolone,azathioprine medication continuously till Novemb
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