Case 3

 CASE:- Chronic kidney disease 

This is an 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 patient's 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 the comment"

A 

Cheif complaint - 

A  40 year old man , is a farmer by occupation came with the complaints of

Pedal edema  since 3 months , along with facial puffiness , Shortness of breathe ( Grade 4) and 

Decreased urine output since 3 months


HISTORY OF PAST ILLNESS:-



Not a known case of hypertension, diabetes, asthma, epilepsy, tuberculosis.


PERSONAL HISTORY:-


Patient takes mixed diet, normal appetite

sleep adequate(sleeps about 6-7 hours at night, wakes up early in the morning for work).

Bowel and bladder habits are regular.

No addictions.



GENERAL EXAMINATION:-


On examination: 

Patient is conscious, coherent

Vitals-

Temp: afebrile

PR: 84. bpm

BP: 130/70 mm hg

RR: 24 cpm

GRBS: 136  mg /dl 

SPo2 - 98% 


No Pallor 

No Icterus

No signs of cyanosis, clubbing, koilonychia. 

Pedal edema is present . 



PER ABDOMEN: soft, non tender

CVS: S1S2 heard

RS: BAE +, NVBS+

CNS: NAD 


Investigations:

Hb: 8.0 gm/ dl

Tlc: 16,800 cells/mm3

Platelets: 4.8 lakhs/mm3

Total bilirubin: 6.9

Direct bilirubin: 2.85 










GENERAL EXAMINATION:-


Treatment - 


Dialysis started on 15/10/21 

Fluid restriction - < 1.5 litres/ day

Salt restriction - <2 g/day 

Tab . Lasix 40mg  BD 

Tab. Nodosis 500 mg BD 

Tab . Shelcal CT OD 

Tab BIO D3 0.24 mg OD

Tab .Orfer  XT OD

Tab . Erythromycin 4000IU /SC 

Cetrizine TID

Syp.Benadryl TID 



2/9/21 - 

Dialysis started on 15/10/21 

Fluid restriction - < 1.5 litres/ day

Salt restriction - <2 g/day 

Tab . Lasix 40mg  BD 

Tab. Nodosis 500 mg BD 

Tab . Shelcal CT OD 

Tab BIO D3 0.24 mg OD

Tab .Orfer  XT OD

Tab . Erythromycin 4000IU /SC 


 28/10/21


Tab . Lasix 40mg  BD 

Tab. Nodosis 500 mg BD 

Tab . Shelcal CT OD 

Tab BIO D3 0.24 mg OD

Tab .Orfer  XT OD

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