55YR OLD PATIENT WITH CKD ON MHD

 "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 and treatment plan "

Chief complaints- 

Complaints of shortness of breath since 2 months and pain in lower back since 2 months.

HOPI- 

Patient was apparently asymptomatic 2 months back then he  had sudden onset of shortness of breath which was insidious in onset grade 2 gradually progressed to grade 4 aggrevated on doing work.ORTHOPNEA and PND present.

No fever ,chest pain.

Decreased urine output since 2 months.Thin stream.poor flow,increased frequency,hesitancy,burning micturition present.

Past History- 

K/C/O DM since 20 yrs.

K/c/o HTN since 6 months.

Not a k/c/o TB,Epilepsy,CVA, CAD, Bronchial Asthma, Thyroid Disorders.

Personal History:

Diet- Mixed

Appetite- normal

Bowel & Bladder Movements- regular

Sleep - Adequate

Addictions - None 

Family History - 

Not significant

General Examination:

- Patient was examined after taking his consent 

- Patient is conscious , coherent , cooperative , well oriented to time , place and person .He is moderately built and nourished 

- No signs of pallor , icterus , cyanosis , clubbing , oedema , lymphadenopathy .

His vitals: 

Temperature : 96.9F

BP : 130/80 mm HG 

Pulse rate : 70bpm

Resp.rate : 20 cpm

GRBS : 118mg/dl

Spo2 : 98 percent 

Systemic examination:

CVS- S1 S2 heard,no murmurs present.

RS - bilateral Air entry present

Normal vesicular breath sounds heard

Per Abdomen : 

soft , Non tender , bowel sounds + , no signs of organomegaly 

CNS :

higher mental functions : normal 

Reflexes : 

MOTOR-: 

normal tone and power 

reflexes:

             RT           L  T

Biceps ++           ++

Triceps ++          ++

Supinator ++       ++

Knee ++              ++

Ankle ++             ++

Investigations:

Provisional diagnosis:

CKD ON MHD