58 year old male with CKD
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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINT:
A 58 Year Old male Tractor driver by occupation presented to OPD with a k/c/o of CKD and chief complaint of shortness of breath,pedal oedema since 4 days and low grade fever,dry cough since 2 days.
HISTORY OF PRESENT ILLNESS:
The Patient was apparently asymptomatic a month back then he developed shortness of breath, decreased micturition and was diagnosed with CKD at local hospital.5 sessions of dialysis was done 20days back in other hospital. Again the patient came here with a c/o pedal oedema and shortness of breath since 4days , low grade fever and dry cough since 2 days.
HISTORY OF PAST ILLNESS:
K/c/o Type 2 Diabetes mellitus
HTN since 6months
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel movements are regular
Regular Alcoholic: consumes 150ml daily since 20 years and chew gutka since 20 years.
FAMILY HISTORY:
Not significant
DRUG HISTORY:
Not allergic to any known drug
GENERAL PHYSICAL EXAMINATION:
The Patient is conscious, coherent and cooperative.Pallor,icterus,cyanosis,clubbing,lymphadenopathy are absent
Pedal oedema is present
VITALS
Temperature: 98.4F
Pulse rate: 76bpm
Respiratory rate: 16cpm
Blood pressure: 90/50mm hg
Spo2: 98@RA
SYSTEMIC EXAMINATION
CVS :- S1 , S2 heard
RS :-Bilateral air entry present
P/A : Soft, non tender
CNS :- sensory system intact
motor system intact
reflexes normal
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS
Chronic Kidney Disease
TREATMENT
T.LASIX 40mg OD
ECOSPIRIN AV 75/10mg OD
T.NODOSIS 500mg PO BD
T.OROFER- XT OD
T.SHELCAL-CT PO OD
