CASE OF 70 YRS OLD FEMALE

A CASE OF 70 YRS OLD FEMALE

August 01, 2023

A 70 year old female presented to the hospital for dialysis.

This is an online e log book to discuss our patient de-identified health data shared after taking his /her guardian signed informed consent. Here we discuss our individual patients problems with collectors 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

A 70 year old female

Housewife by occupation

Resident of kondapakulam came to hospital for dailysis

MAINTENANCE OF DIALYSIS

History of presenting illness:

Patient was apparently asymptomatic 3 years ago, she then developed symptoms of cold, fever,chills and went to hospital and diagnosed by CRF along with Hypertension , increased hemoglobin levels and symptoms relieved temporarily after 3 months on medications she again had facial puffiness and pedal edema,shortness of breath (SOB) grade 2 she went to hospital and she diagnosed by CKD and had a fistula in her right forearm and started dialysis and continued dialysis in kims Narketpally weekly twice from january 1, 2023.

PAST HISTORY:

k/c /o - Hypertension since 3 years

N/k/c- TB, diabetes mellitus, epilepsy, thyroid abnormalities,asthma

PERSONAL HISTORY:

Diet - mixed

 appetite -Normal 

sleep- adequate

Bowel and bladder-normal

No addictions

No allergies

FAMILY HISTORY:

No significant family history

GENERAL EXAMINATION:

prior consent was taken and patient was examined in a well lit room.

patient was conscious ,coherent and cooperative.

pallor present , No icterus, clubbing, cyanosis.

No generalised lymphadenopathy.

No pedal edema on dailysis

Intradialysis fever spikes with chills.

INVESTIGATIONS:

Hyperuricemia - positive

Creatinine levels rised

Hemoglobin level decreased-9.9mg/dl

Provisional diagnosis:

Chronic kidney disease (CKD)