43yr old male with SOB , Anasarca

Ankitha 

Rollno : 78

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 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 diagnosis . 

Cheif Complaints :

C/O SOB since 1 week

C/O Pedal edema since 1 week

C/O Abdominal distension since 1 week

HOPI :

Patient was apparently, asymptomatic 1 year back he started having pedal edema of grade 1 which was reduced on taking medication but gradually progressed to grade 2 and ultimately anasarca. Then he also had complaints of SOB, facial puffiness , distension of abdomen and was taken to private hospital and diagnosed as renal failure , there was persistent increase in creatinine so he was started on hemodialysis  - 18 sessions of dialysis was done. 

Patient came to our hospital 3 months back with same complaints 

From then he is undergoing dialysis in our hospital.

Presently ,

C/O SOB since 1 week - Grade 3 , Orthopnea present , PND present

C/O Swelling of whole body since 1 week gradually progressive (relieved with dialysis and aggravated during nights .)

C/O fever since 1 week , on and off , low grade , intermittent and no chills and rigor.

Past H/O :

K/c/o HTN since 2months on 

Tab.Nicardia 20mg , Tab. MetXL 25mg

Patient was on hemodialysis since 3months

No H/O DM , Cad , Cva , Epilepsy

PERSONAL HISTORY :

DIET : MIXED

APPETITE : Normal 

SLEEP : Inadequate (2-3hrs) due to SOB and pain post iv cannulation

BOWEL AND BLADDER HABITS : REGULAR

NO ALLERGIES

GENERAL EXAMINATION-

PT. IS C/C/C

B/L PEDAL EDEMA OF FEET G-II

NO PALLOR , ICTERUS,CYANOSIS,CLUBBING, LYMPHEDENOPATHY 

Vitals :

TEMP - AFEBRILE

PR-80

BP-140/80MMHG

RR-16CPM

SYSTEMIC EXAMINATION :

CVS-S1S2+,NO MURMURS

RS - BAE+,NVBS , Crepts present

P/A-SOFT,NON TENDER

On percussion - dull note

CNS-NFND

INVESTIGATIONS :

PROVISIONAL DIAGNOSIS : 

CKD ON  MHD secondary to NSAID Abuse

TREATMENT :

1. Tab. NICARDIA 20 mg PO/TID
2. Tab. MET -XL 25mg PO/OD
3. Tab. NODOSIS 500mg PO/BD
4. INJ- LASIX 40mg IV/BD
5. Tab SHELCAL PO/OD
6. SALT RESTRICTION < 2gm/day
7. Fluid Restriction <1lt /day.
8. Intermittent : CPAP