Case 6

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


A 50 year old man presented to OPD with chief complaints of shortness of breath since 3 days. face puffiness,decreased urine output and pedal edema since 3 months.


HISTORY OF PRESENT ILLNESS 

Patient was apparently alright 3 months back then he developed bilateral pedal edema which is pitting type.

No history of chest pain, blurring of vision, loose stool, vomiting, cough, abdominal distinction.


HISTORY OF PAST ILLNESS 

No history of diabetes, asthma, CAD, hypertension, tuberculosis, previous surgery 


PERSONAL HISTORY 

Diet-Mixed

Appetite-Normal

Bowels-regular

Sleep-normal


FAMILY HISTORY 

No history of hypertension, diabetes, heart disease, asthma,cancer, tuberculosis 


GENRAL EXAMINATION 

Patient is conscious,coherent, co-operative and well oriented to time and place 

There is no sign of cynosis, lymphadenopathy, clubbing, icterus, 

Edema is present



VITALS :

Temp :afebrile 

Pulse rate:100/min 

Respiratory rate:26cpm 

Bp:160/90 mm/hg 

Spo2-97%at 8L of o2

Grbs -180mg %


SYSTEMIC EXAMINATION:


CVS  :

No thrills 

No cardiac murmurs 

Cardiac sounds-s1,s2 heard 


RESPIRATORY SYSTEM :

Dysponea-present 

No wheeze 

Position of trachea-central 

Breath sounds-vesicular 


ABDOMEN:

Shape of abdomen-scaphoid 

No tenderness 

No palpable mass 

Hernial orifices-normal 

No free fluid 

No bruits 

Liver ,spleen-not palpable 

Bowel sounds -yes 


CNS:

Conscious 

Normal speech 

No neck stiffness 

No kernings signs 

Cranial nerves ,motor and sensory system,glasgow scale -normal .


REFLEXES :

Plantars -flexor 


CEREBRAL SIGNS:

No finger -nose in -coordination 

No knee- heel in- coordination

PROVISIONAL DIAGNOSIS 

Chronic kidney disease 



INVESTIGATION 

Day 1






Day 2










TREATMENT:

-Tab .LASIX 40 mg Po/BD 

-Tab NODOSIS 500mg PO OD 

-Tab .PAN 40 mg OD 

-Tab SHELLAC CT PO OD 

-Tab OROFER XT PO BD 

-inj iron sucrose 1amp in 100 ml IV  Weekly once 

-inj erythropoietin 4000 IU/SC weekly once 

-O2 inhalation if spo2<90 % 

-strict I/O Charting 

-BP/PR/RR monitoring 4th hrly.




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