CKD

This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome

A male Patient aged 62 yrs,  daily labour by occupation came to opd with Chief complaints of

    loss of appetite and nausea since one week,

    Shortness of breath on exertion  

    bilateral limb swelling since a week

    Decreased urine output since 5 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 1 week back then he developed loss of appetite and nausea then developed shortness of breath on exertion and bilateral limb swelling since 1 week and then noticed Decreased urine output since 5 days 

HISTORY OF PAST ILLNESS :

Pt was apparently normal 4 yrs back then he developed weakness and pain of bilateral limbs and on medication with pain killers on which the pain was not subsided then xray of spine was done and pt was diagnosed with Decreased bone density (OSTEOPOROSIS)

Pt diagnosed with HYPERTENSION and on hypertensives

No history of diabetes ,asthma

TREATMENT HISTORY :

Pt was on hypertensives and had a tablet daily once

PERSONAL HISTORY. :

Mixed diet

Loss of appetite 

Irregular bowel habit

Decreased urine output

Occasional alcohol drinker

Regular smoking habit

GENERAL EXAMINATION :

Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                        Icterus

                        Cyanosis

                       Generalized lymphadenopathy 

Edema of feet is present 

VITALS :

•Temp - afebrile

•Pulse rate - 80 BPM

•RP - 20/min

•BP - 140/70 mm hg

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM :

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

Pt has Dyspnoea 

•Position of trachea - central

•Breath sounds - vesicular

ABDOMEN

•Shape - scaphoid

•No Tenderness

•No palpable mass

•No free fluid

•Spleen and liver not palpable

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

INVESTIGATIONS :

Complete blood picture

Complete urine examination

ECG

USG abdomen 

S.Creatinine -9.9 mg/dl

Blood Urea-149 mg /dl

Urine is albumin +

PROVISIONAL DIAGNOSIS 

Renal failure

TREATMENT :

Supportive treatment is given

●Tab LASIX 40 mg/BD

●Tab PAN 40mg /OD

●Tab NODOSIS 500 mg/OD

●Tab SHELCAL 500mg/OD

●Tab MVT

●BP/TEMP/PR/SP02 monitoring 4th hrly

●GRBS 12th hrly