The 26 year-old male with Shortness of breath , Bilateral pedal edem and Decreased urine output .
Hi, I am Shivraj Sontakke, 3rd semester medical student.
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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Chief compliance :
This is the case of a 26 year-old male who came to the OPD with chief complaints of Shortness of breath of since 10 days Bilateral pedal edem Decreased urine output since 10 days
History of present illness :
The patient was apparently asymptomatic 10 days back. Then he developed shortness of breath which was associated with pedal edema and decreased urine output.
History of past illness :
K/c/o Hypertension since 10 years
The patient is not a known case of Diabetes, epilepsy, asthma, CAD.
Personal history:
•Mixed diet
•Loss of appetite
•Sleep adequate
•Bowel and Bladder movements regular.
Treatment history:
•k/c/o HTN since 10 years
• Not k/c/o diabetes,CAD , asthma, TB.
•NO H/O chemo /radiation , blood transfusion.
•NO H/O previous surgeries.
Family history :
Not significant.
General examination :
Patient is conscious, coherent and cooperative
•Moderately built and Moderately nourished
•No signs of - Cyanosis, clubbing, icterus, lymphadenopathy
•Pedal edema and Pallor present
Vitals:
Temp: Afibrile
PR: 86bpm
BP: 130/90mm hg
RR: 22cpm
Systemic Examination:
1) CVS examination :
CVS: s1s2 heard
•No murmurs
Respiratory system examination :
•NVBS heard
•Breath sounds - vesicular
RS: BAE+ NVBS+
Abdomen examination :
P/A: soft, non tender, bowels sounds heard
CNS Examination
•Intact
•No focal defect
CNS: NFND
INVESTIGATIONS
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
CKD on MHD
TREATMENT
• Fluid restriction <1.5L/Day
• Salt restriction <2G/day
• TAB NICARDIA 10MG/PO/BD
• TAB LASIX 40MG/PO/BD
• TAB NODOSIS 550MG/PO/OD
• TAB SHELCAL 500MG/PO/OD
• TAB OROFER XT PO/OD
• INJ ERYTHROPOEITIN 4000IU weekly once
