70 year old male with CKD

7 March 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

CHIEF COMPLAINT:
 
 70 year old Male patient,farmer by occupation ,came to the OPD with chief complaint of shortness of breath since 2 months ,pedal edema since 2 months

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 20 years ago

20 years ago-pt complained of fever continuously ,Went to a local hospital and was diagnosed with Diabetis and Hypertension

2 yrs back pt developed B/L pedal edema, diagnosed with renal failure 


HISTORY OF PAST ILLNESS:

 Known case of Hypertension and Diabetes

Not a K/C/O of Tuberculosis,Asthma,CAD

PERSONAL HISTORY:

Appetite - Normal

Diet- mixed

Bowel movement- regular

No allergies

Alcoholic regularly

Smoking

GENERAL EXAMINATION:
- patient is Conscious,coherent and cooperative 

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of finger 

-Bilateral pedal edema

Vitals:
Temperature-afebrile
Pulse rate -78 bpm
Respiration rate -18cpm
Bp-150/90 mm Hg
Spo -99%

SYSTEMIC EXAMINATION:

▪️CVS

- No thrills

- No cardiac murmurs

S1 & S2 sounds are heard

▪️ RESPIRATORY SYSTEM

-BAE present

▪️CNS

-HMF intact

INVESTIGATIONS:
Serology :negative
Provisional diagnosis:CKD On MHD



Chest X-ray:
TREATMENT:
Fluid and Salt restriction
T. LAXIS 40 mg PO/ BD
T.NICARDIA 10 mg  PO/BD
T.OROFER XT PO/BD
T.NODOSIS 500 mg PO/BD
T.SHELCAL CT PO/BD





 


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