Case history- 12

 This is an online E- log book to discuss our patient's de- identified health data shared informed 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 50 year old male patient came to OPD with chief complaints of shortness of breath, swelling of legs and decreased urine output since 1 year.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 year back and then  he noticed shortness of breath, swelling of legs, decreased urine output, giddiness and  weakness since 1 year.

No history of palpitations and burning micturition.

PAST HISTORY:

Patient is hypertensive since 4 years.

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

No history of any surgeries in the past. 

PERSONAL HISTORY:

Appetite: low

Diet: vegetarian

Sleep: inadequate 

Bowel and bladder movements: regular 

Micturition: decreased urine output

Addictions:  Alcohol consumption and

smoking since 20 years.

FAMILY HISTORY:

There is no history of similar complaints in the family.

TREATMENT HISTORY:

Patient was on regular medication for hypertension.   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 icterus, cyanosis, clubbing and generalised lymphadenopathy.

Pallor - present 

There is bipedal edema of pitting type.















VITALS:

Temperature: afebrile

Blood pressure:  140/90 mm Hg

Pulse rate:  86 beats / min

Respiratory rate: 16/ min

Spo2 : 98% at room temperature 


SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea- no

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:

               COMPLETE BLOOD PICTURE 

                  


            LIVER FUNCTION TEST 


     BLOOD GROUPING AND RH TYPE



                   HBsAg- RAPID


             

                            RFT


                              ECG



DIAGNOSIS:

Chronic kidney disease on maintenance hemodialysis 

TREATMENT:

1. Tab. NICARDIA 10mg TID

2 . Tab. PAN 40mg OD

3. Tab. LASIX 40mg BD

4. Tab. NODOSIS  500mg BD

5. Tab. SHELCAL 500mg OD

6. Tab. Bio D3 0.25mg OD













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