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

*Vitals**

Temperature- Afebrile

Pulse rate -82bpm

Resp rate - 18cpm

Blood pressure-110/70mmHg

sPo2 98% at room temperature

SYSTEMIC EXAMINATION:: 

SYST

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

PROVISIONAL DIAGNOSIS::

**CKD ON MHD**

INVESTIGATIONS-- 

CBP

CUE

#BLOOD GROUPING

HIV TEST

Anti HCV ANTIBODIES

HBSAG

SERUM IRON

RFT

RBS

TREATMENT ::

*Lasix 40 mg po/bd 

*Clinidipine 

*Metformin 

*Arkamin 

*Thyronorm 

*Nodosis 500 mg

 

*Shelcal 50mg

 

*Orofer