57 yr old male with shortness of breath since 5 days

 


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 box.


Chief complaints-

Swelling of limbs since 2 weeks 

Cough since 2 weeks

Shortness of breath since 5 days 

History of present illness-

Pt was apparently assymptomatic 2 weeks ago then he developed swelling in lower limbs which is insidious in onset gradually progressive in upper limbs and now to the entire body ,pain is not relieved on medication 

No H/O  palpitation, sweating, vomiting , loose stools

No H/O fever 

History of past illness-

K/C/O diabetes type 2

K/C/O hypertension since 7 years 

N/K/C/O Tb , asthma , epilepsy,CAD,CVD

NO past surgical history



Personal history-

Married 

Appetite is normal 

Mixed diet

Micturition- oliguria

Bowel and bladder movements are regular

Adequate sleep


Family history- not significant 


Physical examination- 


General examination-

Pallor , cyanosis, icterus, clubbing,lymapadenopathy is absent 

Oedema is present 


Vitals-

Temp- 98.2

Pulse rate - 86/min

Respiratory rate-18/min

Bp- 130/90mm/hg

Spo2 is 98% 

GRBS-112mg%


Systemic examination -

CVS- s1,s2 heard no murmurs 

RS- no wheezing , no dysponea, vesicular breath sounds heard

Per abdomen examination- shape is scaphoid, no tenderness, no organomegaly

Bowel sounds not heard

CNS- concsious 

Speech normal


INVESTIGATIONS

Haemglobin

Random blood sugar

Blood urea

Serum creatinine

LFT

Serum electrolytes

Serum iron

HIV 1/2rapid test

Anti HCV antibiotics

Haemogram

CUE

blood group and Rh 

      














Provisional diagnosis - chronic kidney disease with history of hypertension and diabetes mellitus from past 7 yrs


Treatment history-

Fluid restriction<2lts /day

Salt restriction<2gm/day

Inj lasix 40mg

Tab vit c

Tab pcm 650 mg

Tab nodosis 500mg

Tab orofet cl

Tab nicardia 20mg

Syrup ascoryl d 10ml


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