1801006086 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. 

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 November 2022

In November she was admitted in our hospital , emergency due to shortness of breath on exertion which is sudden in onset gradually progressed to shortness of breath at rest ,they diagnosed it  as kidney failure and did dialysis for four times and sent her home with some medication.She was also diagnosed with hypertension and started on nicardia 30 mg .

But after 2 months on February 5 th she was admitted to hospital with history of  vomitings and diarrhea since 10 days and diagnosed as acute kidney injury on chronic renal failure,  they started her on dialysis and prescribed with  below medication 

Rabeprazole + domperidone 

Tab orofer xt po/od 8am 

Tab shelcal 500mg po/od 

Tab sodium bicarbonate 500mg po/bd 

Tab nicardia 20mg po/tid 

Probiotics  

Since then she is coming to hospital for regular dialysis that is once in 3 days . 

H/o edema of legs upto knees since 3 days , pitting type which is insidious in onset gradually progressive. 

H/o reduced urine output 

H/o puffiness around the eyes since 3 days ,prominent during morning and subsides by night 

Past history :-

Diagnosed with hypertension 5 months back ( on November 2022 secondary to kidney failure) and on regular medication.

Not a known case of diabetes mellitus, tuberculosis, thyroid disorders, epilepsy 

*Personal history:-

Daily routine:  Her day starts at 7 AM ,she used to get ready for  work and went to office by 8 AM ,used to have breakfast around 10 am in the office  ,her work was more of  attending client calls with 1 to 2 breaks in between till 6 PM more of sedentary work ,sleeps at 11 pm .But since one month she is staying at home ,she has quit her job due to regular dialysis.

Diet - mixed

Appatite- loss of appetite

Sleep- adequate

Bowel and bladder - bowel regular, reduced urine output 

No Addictions 

*Family history:- 

Mother is known diabetic

No history of autoimmune diseases in the family. 

MENSTRUAL HISTROY:

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:-

Patient is conscious, coherent, cooperative

Well oriented to time, place and person,moderately nourished thin built.

 Pallor:- present

Icterus:  absent 

cyanosis :absent

clubbing : absent

generalized lymphadenopathy : absent

Bilateral pedal edema present, pitting type

Systemic examination:-

CVS: 

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

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

Provisional diagnosis:  Chronic Renal failure secondary to lupus nephritis on maintaining hemodialysis.

INVESTIGATIONS:

15.03.2023

Blood urea -79 mg/dl (N=12 to 42 mg/dl)

Serum creatinine-4mg/dl(N 0.6 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:

Urea:157mg/dl

Creatinine :6.9 mg/dl.

Uric acid :6.5 mg/dl.

*Treatment:

Tab Nicradia 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.

Tab biod3 po/ weekly twice .