42 Yr old male CKD ON MHD
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
A 43 years male patient driver by occupation , resident of nalgonda came to casuality with chief complaints of shortness of breath on exertion since 10 days and Bilateral pedal edema since 1week.
HISTORY OF PRESENT ILLNESS :-
Patient was apparently asymptomatic 9 years ago.
Then he developed fever which is insidious in onset and gradually progressive ,for which he went to the local hospital and few blood test was done and daigonised as Diabetic and Hypertension.
Agian after 1year he developed fever and went to local hospital and diagnosed as kidney problem.
Since then he was using medication for both daibetes and Hypertension.
He also developed syncope along with blurring of vision while he was driving,so he discontinued his profession 3 yrs ago.Now he is working as a auto driver.
He stopped medication since 8months and developed bilateral pedal edema for which he went for dailysis.
Since 8 months patient is on dailysis.
PAST HISTORY:
Patient is a known case hypertension , diabetes,since 8 years and on medication.
Not a known case of tuberculosis, asthma, epilepsy.
PERSONAL HISTORY:
Diet - mixed
Appetite-Normal
Bowel and Bladder movements-Regular
Sleep- adequate
##Addictions
""Alcohol intake around 90-180 ml since 20yrs "" occasionally
FAMILY HISTORY::
Not significant
ON EXAMINATION:
Patient was conscious, coherent, cooperative and we'll oriented to time place and person
GENERAL PHYSICAL EXAMINATION:
Pallor-present
Icterus- absent
Cyanosis- absent
Clubbing- absent
Generalized lymphadenopathy- absent
Temperature- Afebrile
Pulse rate -82bpm
Resp rate - 18cpm
Blood pressure-110/70mmHg
sPo2 98% at room temperature
SYSTEMIC EXAMINATION::
1.CVS
**S1 ,S2 heard
**No murmurs.
2.Respiratory system
**Dyspnoea- No
**Wheeze -No
**Position of trachea-Central
**Breath sounds-vesicular
3.ABDOMEN
**Shape of abdomen-scaphoid
**Tenderness-No
** Palpable mass-No
** Liver- Not palpable
**Spleen - Not palpable
**Bowel sounds - No
4.CNS
** No abnormalities detected
**CVS: Inspection
Chest wall is bilaterally symmetrical
No precordial bulge is seen
Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line
Auscaltation
S1&S2 are heard,no murmur found.
**CNS
Patient is conscious
Speech normal
No signs of meningeal irritating
Motor and sensory system- Normal
Reflexes - present
Cranial nerves - intact
**CKD ON MHD**
INVESTIGATIONS--
CBP
RFT
*Lasix 40 mg po/bd
*Clinidipine
*Metformin
*Arkamin
*Thyronorm
*Nodosis 500 mg
*Shelcal 50mg
*Orofer
Comments
Post a Comment