67 YR OLD 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 pedal oedema and facial puffiness since 3 days 


HOPI- 


Patient was apparently asymptomatic 1 week back then she had h/o fever since 3 days with body pains for which she used analgesia and antipyretics after which she developed pedal oedema of pitting type extending upto level of below knee that is insidious in onset without any associating and relieving factors. 


No h/o SOB, Decreased urine output, palpitations, orthopnoea. 




Past History- 




Not a K/C/O DM, HTN,TB,Epilepsy,CVA, CAD, Bronchial Asthma, Thyroid Disorders.


Drug History -

History of NSAIDs use since 10 yrs ,2-3 times a month for knee joint pains.


Personal History:


Diet- Mixed


Appetite- normal


Bowel & Bladder Movements- regular


Sleep - Adequate


Addictions - None 


Family History - Not significant




GENERAL EXAMINATION-




Patient is Conscious, Coherent and Co operative .






No signs of Pallor ,Icterus Clubbing, Cyanosis, Lymphadenopathy and edema




Vitals-


TEMP: 98.4°F 


BP: 100/70mmHg


PR: 86bpm


RR- 21cpm


Spo2- 98% @RA




Systemic Examination:




CVS: Inspection


Chest wall is bilaterally symmetrical.


No precordial bulge is seen 




Palpation








JVP- Normal




Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 




Auscaltation-




S1&S2 are heard,no murmur found.








RESPIRATORY SYSTEM








Position of trachea- central




Bilateral air entry, normal vesicular breath sounds are heard.




No added sounds








CNS


Patient is conscious ,coherent and co operative , well oriented to time and space.




Speech normal.




No signs of meningeal irritation.




Motor and sensory system- Normal




Reflexes - present




Cranial nerves - intact


On inspection:


Abdominal distention - absent


On percussion::


Tympanic note - heard 


No shifting dullness



On auscaltation::


Bowel sounds heard

Provisional diagnosis:CKD ON MHD





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