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