This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box
History of presenting illness: Patient was apparently asymptomatic till 2017 then she had loss of patches of hair ,joint pains and oral ulcers and was diagnosed with Systemic lupus erythematosis. 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).
Patient presented with shortness of breath since 2days 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
11. Inform SOS
Comments
Post a Comment