80 YRS OLD MALE CAME TO CASUALTY WITH C/O LOSS OF CONSCIOUSNESS (FOR HALF AN HOUR) C/O INVOLUNTARY BOWEL AND BLADDER INCONTINENCE AND SLURRED SPEECH SINCE 4AM TODAY

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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 42 year old female came to the OPD with C/o

   -pitting type of pedal edema since 11months

   -facial puffiness since 11 months

   -decreased urine output since 11months

  - Shortness of breath (SOB) since 3 months

  - Abdominal distension since 3 months

Patient was apparently asymptomatic 11 months back, then in jan'21 ; she developed

• swelling in both feet, ankles,legs 

Which was insidious in onset, gradually progressive ( started in feet and ankles and progressed upto thighs (i.e) grade-3)

• decreased urine output since 11 months

• Shortness of breath since 3 months, insidious in onset gradually progressive

 (NYHA grade-3 )

• Abdominal distension since 3 months

NO H/O chest pain, palipations, fever , sore throat, joint pains.

NO H/O hemoptysis , wheezing

NO H/O pain abdomen , jaundice

Past history:

  •2 years ago ,She complaints of  giddiness & went to  RMP & was  diagnosed with HTN & on tab. Nifedipine 10mg /PO/OD ( Irregular)

She was diagnosed with CKD and is on  hemodialysis since 11 months 

No DM,TB, ASTHMA, EPILEPSY

Personal history:

 appetite - decreased

Sleep - disturbed

Urine output-decreased

Bowel movements- regular

No addictions

No significant family history

Surgical history :

1 cesarean section & tubectomy

General physical examination:

Patient is conscious, coherent, cooperative

Moderately built & nourished

 

Pallor - +

No icterus, cyanosis, clubbing,koilonychia, lymphadenopathy.

Edema- + (pitting type)

Arterio- venous fistula for hemodialysis is present on right forearm with palpable thrill 

Vitals: 

Temp- afebrile

BP - 150/90 mm HG

PR -88 BPM

RR- 17 CPM

 Systemic examination:

CVS-. S1S2 heard , no Murmrs

RS - BAE +; NVBS

P/A - soft , non tender

CNS - Hmf intact .

Provisional diagnosis:-

CKD on MHD

USG report-