55 yr old male with CKD 2° to DM
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 inputs.
This e-log book also reflects my patient centred online learning 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 diagnosis and treatment plan.
A 55 yr old male from suryapet came with chief complaints of generalized body swelling since 15 days,shortness of breath since 15 days, decreased urine output since 10 days.
History of presenting illness:
Patient was apparently asymptomatic 15 days ago,then he noticed generalized body swelling and then he also had shortness of breath since 15 days which was insidious in onset, gradually progressive from grade 1 to grade 3.Orthopneais present,no paroxysmal nocturnal dyspnea is not present.Then he also had decreased urine output.
H/o fever since 2 days
Burning micturition is present
No h/o cough,nausea, vomiting,loose stools.
Past history:
K/c/o Diabetes mellitus since 6 years and is on Medication insulin injection,10U TID
K/c/o Hypertension since 1 year and is on Medication Amlodipine 10 mg OD
K/c/o CKD since 1 year and on conservative management.
Not a k/c/o asthma, tuberculosis,blood transfusion.
No h/o past surgeries.
No h/o usage of antibiotics.
Personal history:
Normal appetite
Mixed diet
Irregular bowel and bladder movements
No allergies,and he is an regular alocoholic.
Family history:
Not significant
General examination:
No icterus
No cyanosis
No clubbing
No lymphadenopathy
Vitals:
Temperature -Afebrile
RR-18cpm
Pulse -86bpm
BP-130/80
Systemic examination:
CVS-S1S2 heard,no murmurs,no thrills
RS-Normal vesicular breath sounds heard,trachea is central
P/A-soft,nontender,no organomegaly
Liver and spleen not palpable
No free fluid,no bruits,no palpable mass
CNS-No focal neurological deficits
No cerebellar signs
Investigations:
Ultrasound report
Chronic kidney disease secondary to diabetes(diabetic nephropathy)
Anaemia secondary to CKD
Treatment:
Inj.Insulin
Tab.Amlodipine 10 mg PO OD
Tab.Nodosis 500 mg PO BD
Inj.Iron sucrose 200 mg in 100 ml NS IV/OD
Tab PCM 650 mg PO
Comments
Post a Comment