Osce questions and learning points.

 8th December 2023

Osce questions:

1)  Hypertension causing chronic kidney disease vs chronic kidney disease leading to hypertension?

Chronic kidney disease (CKD) is both a common cause of hypertension and CKD is also a complication of uncontrolled hypertension. 

Ckd causing hypertension:

CKD have higher prevalence of traditional risk factors for atherosclerosis, hypertension, diabetes however additional mechanism of cardiovascular diseases may also be implicated. left ventricular hypertrophy is commonly found in patients with CKD secondary to hypertension and anaemia. Calcification of the media of blood vessels also occurs.

The pathophysiology of CKD associated hypertension is multi-factorial with different mechanisms contributing to hypertension. These pathogenic mechanisms include sodium dysregulation, increased sympathetic nervous system and alterations in renin angiotensin aldosterone system activity.

A target blood pressure of 140/90 mmHg is recommended for patients with ckd.

Hypertension causing ckd:

High blood pressure can constrict and narrow the blood vessels, which eventually damages and weakens them throughout the body, including in the kidneys. The narrowing reduces blood flow.

Kidneys no longer work properly and are not able to remove all wastes and extra fluid from your body. Extra fluid in the blood vessels can raise blood pressure even more, creating a dangerous cycle, and cause more damage leading to kidney failure.

2) At what levels of urea and creatinine diuretics can't work and dialysis is done?

Urea levels-35.7mmol/litre

Creatinine levels- 29% 

As kidneys are severely damaged the urine cannot be excreted so there is no use in taking diuretics for edema so then dialysis is recommended.

References: Davidson's textbook, https://pubmed.ncbi.nlm.nih.gov/2787322

Learning points:

* I have learnt how to differentiate between edema caused due to cardiac failure and chronic kidney disease from the basics.

* I have learnt the mechanisms behind how ckd causes hypertension and cardiac failure and how hypertension causes kidney disease.

* I have learnt the various types of access to the dialysis (central venous catheter, arteriovenous fistula, av graft) and types of av fistulas and regarding dialysis procedure 

* I have developed my communication skills and interpersonal relationship with the patient and her attenders.

76 yr old female with pedal edema.

 6th December 2023

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

Date of admission - 6th December 2023

A 76 year old lady home maker by occupation resident of nalgonda came to opd with chief complaints of 

Pedal edema and shortness of breath since 4 days.

Decreased urine output since 4 days.

History of present illness:

She was apparently asymptomatic 1 month back then developed loss of appetite, indigestion, nausea and vomitings since 1 month for which she was taken to hospital and found to have raised urea and creatinine levels and was suggested to get dialysis done.

she presented with bilateral pedal edema pitting type extending upto the knee since 4 days.

Shortness of breath grade(1-2) since 4 days.

No history of chest pain and palpitations.

No history of burning micturition.

Daily routine before the onset of disease:  

wakes up at 6:00 am.

Does all the household works like cooking, and cleaning utensils and tailoring work.

1-2 pm - eats lunch, sleeps after having lunch.

wakes up at around 4:00 pm does some stitching work or watches Tv.

Dinner around 8pm and sleeps after dinner.

Past history:

Known case of hypertension since 4 years and on medication clinod-t (clinidipine 10mg and telmisartan 40 mg).

Not a known case of DM, asthma, TB, epilepsy, CAD, CVD and thyroid diseases.

Personal history:

Diet :mixed 

Appetite: decreased 

Bowel and bladder movements regular 

Sleep: adequate 

No allergies and addictions 

Family history:  not significant

General examination:

Patient is conscious, coherent and cooperative.

Well oriented to time and place.

Moderately built and nourished.

Pallor- absent 

Icterus - absent 

No clubbing, cyanosis and lymphadenopathy.

Pedal edema- present 

Vitals:

Temp: 98.2 f

Bp: 120/80mm hg

PR: 88 bpm

RR: 16cpm

Systemic examination:

CVS:s1s2+,no murmur

RS:BAE+,no added sounds 

P/A: 

Inspection: Shape of abdomen- slightly distended.

Position of umbilicus: central and inverted

No scars and sinuses are present

All quadrants are moving equally with respiration

Palpation:No tenderness 

No organomegaly

Auscultation:

Bowel sounds heard 

CNS: NFD

Investigations:

ECG: 

Provisional diagnosis - chronic kidney disease on mhd.

Treatment given-