70 year old female. nsaid abuse prefinal examination

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 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 plan. 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 evident based input. 



Chief complaints
  • A 70 year old Female Patient came to OPD, for her regular check up
  • She was admitted on the basis of deranged Renal Function tests

History of present illness
   
  • The patient was apparently asymptomatic 2 years back, when she developed COVID -19, and went to a hospital where she was diagnosed with CKD, based on her raised Urea and Creatine. 
  • On further questioning she reported to have had a Fracture of her Left Hand 4 years ago, for which she was prescribed NSAIDS, and was taking them on and off since then.
  • She also developed Pedal Edema 1 year back which was pitting type.
  • Decreased Urine output since 1 year.
  • There is no history of fever, Shortness of breath, palpitations, Chest pain, cough or burning micturation
TIMELINE OF EVENTS:

2019 - Fracture of Left Hand, Started NSAIDS

2021 - Infected with COVID -19, got diagnosed with CKD

2022 - Developed Pedal Edema, Decreased Urine Output

4.01.2023 - Admitted for Hemodialysis 


Past history
  •  The patient is a known Hypertensive since 2 years.
  • The patient is not a known case of DM, Asthma, TB, Epilepsy
Family history
  • No relevant family history. 
Personal history
Diet - Mixed
Appetite - Normal
Bowel and Bladder - Regular
Sleep - Adequate
Addictions - None

Treatment history
  • Patient is on medication for Hypertension. 
General examination 
The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 
Moderately built and well nourished
Presence of pallor 
Edema of Lower Limbs is present
No icterus, cyanosis, clubbing, lymphadenopathy 
Vitals
,Temp: Afebrile
PR: 126 bpm
BP: 130/90 mm Hg
RR: 38 cpm
SPO2: 98% 

Systemic examination 
Patient is examined in a well lit room and in a sitting position
Respiratory system
Normal vesicular breath sounds Heard
Cvs
S1,S2 heard
No murmur
Per abdomen

INSPECTION:  Shape of Abdomen -  Normal, No sinuses, fistulas. Umbillicus -  Central, not everted

PALPATION: Inspectory Findings Confirmed

Soft, non tender

No Organomegaly

PERCUSSION : Tympanic

AUSCULTATION:  Bowel sounds Heard

CNS

No focal neurological deficits 

Cranial Nerves intact.

Clinical picture



Provisional diagnosis

CHRONIC RENAL FAILURE  - Secondary to NSAID abuse. Based on history and systemic examination 

Investigations


                    19-7- 2021



                   28-9-2021

 3-1-2023

3-1-2023

.   Hemogram.  4-1-2023

.           4-1-2023

.             4-1-2023

.              4-1-2023

.              4-1-2023

.          4-1-2023

.            4-1-2023

 

          4-1-2023

.            4-1-2023

.           4-1-2023

.          4-1-2023

            4-1-2023

.    4-1-2023

. Ultra sound 4-1-2023

Treatment

  • Tab. LASIX
  • Tab. MINIPRESS
  • Tab. NODOSIS
  • Tab. SHELCAL
  • Tab. OROFER
  • Inj. EPOtin
  • HEMODIALYSIS
 diagnosis

CKD 2° TO NSAID ABUSEA

NEMIA 2° CKD 

AKI ON CKD 

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