A 46y old female with ulcer over left leg and CKD on MHD

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 MARCH 11,2022

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

K.TEJA SREE , ROLL NO:54 ,  9th SEM

CASE

A 46y old female came to the hospital for dialysis 

HOPI:

Patient was apparently asymptomatic 5yrs back then she underwent surgery for right eye and surgery and wasn’t successful and patient was on continuous pain killers since then.
Then 1 1/2 year back patient went for regular checkup and found out serum creatinine was 6.0 and was on medication since then. 
On Jan 18th 2022 she had SOB even at rest and was admitted at local hospital and found out serum creatinine was 14.0 so a femoral line was placed for dialysis and underwent 4 sessions of dialysis with this femoral line. Following which the vein got clotted and led to progressive swelling and discolouration of the left leg and now led to ulcer formation.


The femoral line was then removed and subclavian line was placed and underwent 12 sessions of dialysis till day in various local hospitals.

PAST HISTORY:
.she is a known case of 
DM since 15years and on oral hypoglycaemia drugs 
HTN since 20years and on metaprolol,
Not a case of  CAD, Asthma, TB.epilepsy
Surgery done for right eye 5years back

PERSONAL HISTORY :
Appetite: normal
Diet : vegetarian 
Bladder and bowel: Regular 
Micturition : normal
Sleep :adequate
No addictions and no allergies 
 
No significant family history.

GENERAL EXAMNATION:
Patient is c/c/c. 
pallor present 



 No icterus, cyanosis, clubbing, lymphadenopathy,
Bilateral  pedel edema present more on the left side
- left leg- edema till thigh
- right leg- edema till knee




VITALS:
temp: 98 F
PR: 96 bpm
RR: 18 cpm.
BP: 180/90 mmhg.

 
 RESPIRATORY SYSTEM:
  • position of trachea - central
  •  normal vesicular breath sounds
  •  Bilateral air entry present 

Abdomen: soft and non-tender. 

CVS: S1,  S2 heard
          no thrills and murmurs.
CNS: Normal and intact

INVESTIGATIONS:
On 09/3/2022
  • Blood urea-73mg/dl


  • Serum creatinine-6.1mg/dl


  • Hb-8.3g/dl




On 10/3/2022

  • Direct bilirubin-0.26*
  • ALP-790*
  • Total proteins-5.5*
  • Albumin-2.1*

  • Hemoglobin-8.0*
  • Pcv-23.3
  • MCC-82*
  • RDW-cv- 15*
  • RBC COUNT-2.34*millions/cu.mm



  • Urea-93*
  • Creatinine-6.8*
  • Uric acid-7*
  • Phosphorus-4.6*

On 11/03/2022





PROVISIONAL DIAGNOSIS 
CKD on MHD with ulcer over left leg

TREATMENT 
10/3/2022
  • Fluid restriction <1.5ml/day
  • Salt restriction <2g/day
  • Tab.40mg OD
  • Inj.HAI ,SC  according to GRBS
  • Inj. Iron sucrose 100mg weekly once in 100ml NS
  • Tab. Erythropoietin once in week
  • Tab. Nicardia 20mg
  • Tab. Lasix 40mg BD
  • Tab. Bio D3 OD
  • Tab. Orofer
  • Tab.shellcal 500mg OD
  • Monitor vitals

11/3/2022
  • Fluid restriction <1.5ml/day
  • Salt restriction <2g/day
  • Tab.40mg OD
  • Inj.HAI ,SC  according to GRBS
  • Inj. Iron sucrose 100mg weekly once in 100ml NS
  • Tab. Erythropoietin once in week
  • Tab. Nicardia 20mg
  • Tab. Lasix 40mg BD
  • Tab. Bio D3 OD
  • Tab. Orofer
  • Tab.shellcal 500mg OD
  • Monitor vitals
On 12/3/2022 discharged 





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