23 CH.AKHILA

 A 50 YEAR OLD MALE

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I have 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.

A 50 year old male, came to the casuality with chief complaints of 

1.Facial puffiness and leg swelling since 6months

2.Associated with SOB with grade 2

HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptotic 6months back the he developed facial puffiness and bilateral pedal edema which was painless and it is of pitting type. He also complained of shortness of breath which is of grade 2 and decreased urine output there is no history of fever, nausea and vomiting

PAST ILLNESS:

He was diagnosed with hypertension 1year back, there is no history of diabetes, TB, asthma.

PERSONAL HISTORY:

Appetite: decreased since 6months

Diet : mixed

Bowel : normal 

Bladder : Abnormal (decreased urine output) 

Sleep : Adequate 

Addictions : Alcohol - consumes regularly since 30 years 

Tobacco : Beedi - daily 1pack since 30years and stopped 4years back

FAMILY HISTORY : Not significant 

GENERAL EXAMINATION: 

Moderately built and moderately nourished 

Pallor - Present 

No icterus, cyanosis, clubbing, lymphadenopathy.

Vitals: 

Temperature - Afebrile

Pulse - 86bpm

BP - 140/80mmhg

SYSTEMIC EXAMINATION:

CVS : S1&S2 heard

RESPIRATORY SYSTEM : SOB grade 2

ABDOMEN : Normal

CNS : consciousness and speech is normal 

                      Random blood sugar

                         Serum creatinine 

                   

                      Blood urea 

                      Complete blood picture 

                     Serum electrolytes 

                      Complete urine examination 

ECG : 

PROVISIONAL DIAGNOSIS:

CKD on MHD

  

TREATMENT:

1) Salt restriction (<2g/day)

2) Fluid restriction (<1L/day)

3) T.LASIX 40mg PO/BD

4) T.NICARDIA 10mg PO/BD

5) T.ARKAMINE 0.1mg PO/BD

6) T.NODOSIS 500mg PO/OD

7) T.OROFER XT PO/BD

8) T.SHELCAL 500mg PO/OD

9) ING ERYTHROPOIETIN 4000IU/IM Twice weekly (post dialysis)