40F crf with heart failure with scleroderma overlap

Name: Meghana Muddada 

Roll no: 95

 This is an online 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 problems with collective current best evident based input

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

Presenting Complaints:

C/o Difficulty in Breathing Since Morning 

C/o Decreased Urine Output Since Morning(Once Since Morning)

C/o Decreased Food Intake Since Morning 

HOPI:

Patient was apparently asymptomatic till 2011 then she had developed pain in both fingers of the upper limbs & damage & peeling of nails of fingers of upper limb then had developed pain wrist & elbow joint & knee pains.

Pt went to hospital & was treated with calcium supplements & used for 3 yrs & patient symptoms subsided then from 1 year back she started developing same symptoms & went to hospital & was diagnosed with SLE on routine investigations.pt was started on medication after six months patient was diagnosed with HTN.pt started having loose stools & vomitings & went to hospital & was having bilateral lower limb swelling & on routine investigations pt found to have devanged renal cutaneous & initiated on hemodialysis involve volume over load & renal parameters 

H/O PAST ILLNESS: 

K/C/O HTN Since 6 Months on medication -

 T.Praxosin Hydrochloride 2.5 mg

T. Arkamin 0.1mg

T.Linod 100mg Po/OD

Not A K/C/O TB/Asthma/Epilepsy/CVA/ DM-II

6 - Sessions Of HEMODIALYSIS Done

2-PRBC Transfusion Done

Treatment history: 
HTN since 6 months 
Diabetics-No
CAD-No
Asthma-No


Personal history: 
Married 
Occupation: Housewife
Decreased appetite
Micturition- Decreased 

General examination: 
Pallor +
Cyanosis +
Oedema + upto knee pitting type 
No icterus clubbing lymphadenopathy malnutrition 
PR-100/min
RR-32c/min
Bp-130/90
Spo2-90% @RA
GRBS-75mg/dl

Systemic examination:
CVS: s1 s2 heard, no murmurs
RS: BAE + , NVBS
P/a : tenderness + left hypochondrium 
Cns: pt is C/C/C 
No FND
HMF

Investigations




















Diagnosis:
CRF WITH HEART FAILURE WITH SCLERODERMA OVERLAP WITH K/C/O SLE SINCE 14 Years
WITH K/C/O HTN SINCE 6 Months

Treatment:
Inj.Monocef 1g/BD
Inj.Lasix 40mg IV/BD
T.Prazosin Hydrochloride 5mg PO/TID
T.Arkamine 0.1 mg PO/TID
T.Nicaradia Retard 20mg PO/TID
T.Nodosis 500mg PO/BD
Intermittent CPAP

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