CHRONIC KIDEY DISEASE(CKD) IN HYPERTENSIVE WOMEN;

 GENERAL MEDICINE CASE REPORT;

2 AUGUST,2021;

SAI PRANEETH BATHINEEDI;

ROLL NO 116;

3 SEMESTER STUDENT;

HELLO GUYS, This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input

I've 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.

CHIEF COMPLAINT;

A 62 year old female presented to the OPD with chief complaints of;

1. lower back pain 

2. Swelling of the leg 

3. shortness of breath from the past 2 months

HISTORY OF PRESENTING ILLNESS;

The patient was apparently asymptomatic 3 years back;

3 years ago the patient was diagnosed with Hypertension and was started on anti hypertensive medication . 

From the past 6 months , the patient complains of loss of appetite,easy fatigability ,and swelling of the feet. 

2 months ago , the patient developed lower back pain and swelling of legs accompanied with shortness of breath and visited a local hospital , where she was told that she needs to visit a hospital that has a dialysis facility . 

1 month back she visited our hospital and was diagnosed CKD  and was started on hemodialysis . After the first dialysis , the patient had hemoptosis. 

The patient still complains of facial and neck swelling .

She is currently undergoing dialysis 2 sessions  a week . 

PAST HISTORY;

known case of - HYPERTENSION ;

No history  of DM , CAD ;

DRUG HISTORY;

Atenolol 50 mg , for treatment of hypertension .  

PERSONAL HISTORY;

Diet - Mixed diet . 

Occupation - Agriculturist 

Sleep - adequate 

Bowel movements - Regular 

NO history of smoking or alcohol consumption . 

Family HISTORY;

NO significant family history;

MENSTRUAL HISTORY;

She attained menopause at 55 years of age. 

She describes her menstrual cycle as regular .

The patient underwent hysterectomy 10 years ago.

TREATMENT HISTORY AT OUR HOSPITAL;

ON 17/7/21,24/7/21,31/7/21 DATES RESPECTIVELY THE PATIENT UNDERWENT HEMODIALYSIS;