1801006084-SHORT CASE

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. 



 I have 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, and investigations, and come up with a diagnosis and treatment plan.

 45 yr old male patient who is a resident of Nalgonda lorry driver by occupation presented with chief complaints of  

. decreased urine output since 15days

.cough since 15days

.B/L pedal edema since 10days

.facial puffiness since 10days
HOPI:
Patient was apparently asymptomatic 2yrs back then he developed b/l pedal edema and decreased urine output and diagonosed as renal failure.SOB grade-2 insidious in onset gradually progressive 
He also had complaints of cough since 15days facial puffiness since 10days
Past history
K/c/o HTN DM
Not a k/c/o TB asthma epilepsy 
Treatment history
He is using medication Tab Nicardia
And insulin
Family history
No significant family history 
Personal history
Diet :mixed
Appetite:Normal 
Bowel habits regular 
Bladder: irregular 
Addictions:Toddy since childhood,beer-occasionally
GENERAL EXAMINATION:-
Patient is conscious , coherent,cooperative.
Well oriented to time place & person 
Moderate built and moderately nourished.
Pallor present 
No cyanosis, clubbing, icterus, LN and bilateral pedal edema.
Vitals : 
Bp -150/90 mmhg
PR -86 bpm ;
RR : 22cpm
Spo2 : 96 on RA
GRBS:128 mg/dl
CNS:no focal neurological deficit 
CVS:-
S1 S2 heard 
No murmurs.
RESPIRATORY SYSTEM:-
Dyspnea-absent
No wheeze
Breath sounds - vesicular
No Adventitious sounds 
ABDOMINAL EXAMINATION:-no visible scars ,sinus,and engorged veins.
abdomen is soft.
No tenderness 
No palpable liver and spleen and other masses
Bowel sounds - PRESENT


Insulin



 



Investigations:
Haemogram
Hb:8.9
Smear:normocytic normochromic anaemia
RFT
Urea:9.2
Creatinine:9.4
ECG
USG
Raised echogenicity of bilateral kidneys

 Diagnosis:Chronic kidney disease secondary to diabetic nephropathy,with egfr:6ml/min/1.732m² stage V on maintainance Haemodialysis 

Treatment
T.LASIX 40mg p/o BD
T.NICARDIA 20mg p/o BD
T.NODOSIS 500mg p/o BD
T.SHELCAL 500mg p/o OD




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