A 65 year old patient with CKD

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is 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, investigations and come up with diagnosis and treatment plan.



A 65 year old male came to casualty with chief complaints of bilateral pedal edema,shortness of breath, facial puffiness, decrease urine output.

History of presenting illness


Patient was apparently asymptomatic 3 years back then he developed right sided hemiparesis for which he went to hospital where he received medication.After 1 1/2 year, patient had complaint of pedal edema and shortness of breath went to hospital,which was diagnosed as chronic kidney disease and he is on regular medication. and after that he came to our hospital with complaints of pedal edema,Shortness of breath Grade 2-3, decreased urine output.

Past history

Known case of diabetes in 3 years and hypertension since 1 year.
 
No H/o asthma,TB,Epilepsy
 

Family History

No relevent Family history

Personal History

Diet:mixed
Appetite:decreased 
Sleep:adequate 
Bowel&Bladder movements:decreased urine output
Addictions:He stopped taking alcohol since 3 years
No history of smoking


General Examination
Patient is conscious coherent and cooperative
No pallor,cyanosis, Icterus, lymphadenopathy, clubbing.
Pedeal edema present

Temperature:98.6
pulse rate:90bpm
RR:25
BP:110/70
spo2:89%

Systemic Examination:
RS: vesicular breath sounds
CVS - S1 &S2 +
P/A - soft and non tender.


Investigations:-

Hemogram:



RFT:



ECG:-



Provisional diagnosis:-
 CKD on MHD.


Treatment:-






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