This is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 .


 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 a diagnosis and treatment plan. 


CASE SCENARIO:

 A 22 yr old  female came to the ward with chief complaints of Bilateral pedal edema,  decreased urine output, shortness of breathe
 in early morning on wakeup.
She had similar complaints in the past.
The patient was apparently asymptomatic 13mnonths back then she had blurring of vision and went to other hospital diagnosed with kidney disease.
k/c/o chronic kidney disease since 1yr
On dialysis since 1yr.
k/c/o Hypertension  since 1yr.

Treatment history:
On medication for hypertension. 

Personal history:
Single
Student
Appetite- lost
Bowels- regular
No allergies
No addictions/habits.

Family history:
Father Is k/c/o Hypertension. 

Physical examination:
On examination 
Pallor present.
No cyanosis ,lymphadenopathy,clubbing,dehydration 
Temperature- 98.5F
Pulse rate- 99 per min
Respiratory rate- 18 per min
spO2 - 99%
GRBS-112mg%

SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No

RESPIRATORY SYSTEM
Dyspnoea:no
Wheeze: No
Position of trachea: Central 
Breath sounds: Vesicular 
Adventitious sounds : No

ABDOMEN
Shape - Scaphoid 
No tenderness, palpable mass, 
No Fluid 
No bruits

CENTRAL NERVOUS SYSTEM
Level of consciousness - conscious
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit 

Reflexes 
     
       Biceps  Triceps  Supinator  Knee  Ankle 

Right    2+      2+            2+          2+     2+          

Left      2+       2+      2+     2+ 2+

PROVISIONAL DIAGNOSIS:
CKD on MHD
Investigations  - hemogram ,RFT,USG abdomen,serology.



Treatment :
1.Fluid resistriction <1l/day
2.salt restriction <2.4 g/day
3.Tab LASIX 40mg/PO/TID   
      1   - 1  - 1
4.Tab NICARDIA 20mg/PO/BD
    1  -  x   -  1
5.Tab OROFER xt /PO/OD
     x  -  1  -   x
6.Tab SHELCAL/PO/OD
     x  -   1  -  x
7.Inj ERYTHROPOIETIN 400IU/IM
8. Inj Iron sucrose 1 Amp in 100 ml / during dialysis. 
9.Tab NODOSIS 550mg/PO/BD
    1  -  x  -   1

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