Short case elog

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.

A 40year old male , resident of tummatuti, farmer by occupation came to OPD with

Chief complaints of 

• Shortness of breath since 6 days
• Bilateral pedal edema since 4 days

History of presenting illness

Patient was apparently asymptomatic 6 days ago, then he developed shortness of breath , which was insidious in onset and gradually progressed from grade 2 to grade 3.

Then he developed bilateral pedal oedema , pitting type, insidious in onset ,gradually progressive and present throughout the day and increased on walking. No relieving factors.

No H/o decreased urine output, burning micturition and  chest pain , fever

Past History

H/o similar complaints 4 months ago

K/c/o hypertension since 12 years

H/o NSAID abuse since 7 years

K/c/o diabetes mellitus since 7 years

K/c/o chronic kidney disease since 4 months

Patient has undergone 6 sessions of dialysis till now

Not a k/c/o TB , EPILEPSY, asthma.

Family history - Not significant

Personal history

Diet : Mixed

Appetite : Normal

Sleep: Adequate

Bowel and bladder movements : Regular

Was a chronic smoker and alcoholic 

No known drug allergies

 General physical examination:

Patient is conscious, coherent , co-operative, moderately built and moderately nourished.

Pallor: present

Icterus : absent

Cyanosis: absent

Clubbing: absent

Koilonychia: absent

Lymphadenopathy: absent

Edema : bilateral pedal oedema present

Vitals:

Patient is Afebrile

Pulse : 90 beats/min

Respiratory rate : 20 cycles / min

BP : 140/90 mmHg

SpO2: 95%

GRBS: 140 mg/dl

CNS examination: 

Higher mental functions-normal 

Cranial nerves- intact

Sensory system- normal

Motor system- normal 

Respiratory system examination: 

Normal Vesicular Breath sounds heard , No added sounds

CVS examination:

S1 and S2 heard , No murmurs heard

Per Abdomen: 

Distended abdomen

Umbilicus -Central in position and slit like

Flanks are full

Palpation : No local rise in temperature , No tenderness 

No organomegaly 

Percussion:

Shifting dullness- present

Auscultation: bowel sounds are heard.

Investigations:

RFT: 

urea, creatinine, uric acid and phosporus  levels are elevated

 

Blood Group :A+

Hemogram : 7.8gm% normocytic normochromic anemia

Serum electrolytes: sodium levels slightly decreased

Serum creatinine : elevated

Blood urea : elevated ( markedly )

 Complete urine examination: albumin and sugars are present.      

               USG

Chest xray - Normal

Provisional diagnosis: Chronic kidney disease

Treatment: 

Erythropoietin inj. Weekly

T. Shelcal 500 mg

Tab. Lasix 40 mg

Tab. Telma  40 mg

Tab. Clinidipine - 10 mg TID
Iron sucrose inj. 100mg in 100 ml normal saline

 

Tab. Nodosis 500mg

Syrup : cremaffin plus at night