Case history- 3

 21 September, 2021

" This is an online E- log book to discuss our patient's de- identified health data shared after taking his/ her guardian's  signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This e- log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. "

A 60 year old male patient came to OPD with chief complaints of swelling of the legs , facial puffiness , decreased urine output and shortness of breath. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back and then he noticed swelling of legs, facial puffiness, decreased urine output and shortness of breath. 

PAST HISTORY:

He is a hypertensive patient since 2 months.

No history of diabetes, CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of surgeries in the past. 

PERSONAL HISTORY:

Appetite: low

Diet: mixed

Sleep:  adequate

Bowel and bladder movements: regular

Micturation: normal

Addictions: no

FAMILY HISTORY:

There is  history of  hypertension in the family.

TREATMENT HISTORY:

Patient had not undergone any treatment prior. He is not allergic to any known drugs. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time , place and person.

There is no signs of pallor, icterus, cyanosis, clubbing and generalised lymphadenopathy. 

There is bipedal edema of pitting type.



VITALS:

Temperature:  afebrile

Blood pressure: 140/ 80 mm of Hg

Respiratory rate: 18/ min

Pulse rate: 92/ min

SPO2: 98% at room temperature 

GRBS: 147 mg%

SYSTEMIC EXAMINATION

CARDIO VASCULAR SYSTEM:

No thrills

S1 and S2 sounds are heard

No cardiac murmurs 

RESPIRATORY SYSTEM:

No dyspnoea 

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no

Palpable mass- no

Hernial orifices- normal

Free fluid-  no

Bruits- no

Liver- not palpable

Spleen- not palpable

Bowel sounds- yes

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious

Speech : normal 

Signs of meningeal irritation- 

                  Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

 

RFT 
                 Complete Blood Picture 
                 Blood Sugar -Random
                Liver function test
                    Serum Iron
           Blood grouping and Rh type
                   Hemogram
                  HBsAg- RAPID
                HIV 1/2 Rapid test
                Anti HCV antibodies 

 DIAGNOSIS:

Chronic kidney disease on maintenance hemodialysis 

TREATMENT:

1. Tab. Shelcal

2.Tab. Nodosis

3. Tab. Lasix

4. Tab. Pantop

5. Inj. Erythropoietin weekly twice

6. Inj. Iron sucrose any weekly once






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