final exam short case 1902102072

62 year old male with ckd 

This is an online e log book to discuss our patient deidentified health data shared after taking his /her or gaurdian signature on informed consent . Here we discuss our patients problem through series of input from available global online community of experts with an aim to solve those patients clinical problems woth collective current best evidence based inputs . This e log book also reflects my patient - centered online learning portfolio and your valuable inputs in comments box. 
Chief complaint
A 62 year old male came with a chief complaint of decreased appetite, nausea, vomiting, pedal edema ,  decreased urine output ,facial puffiness since 15 days . 
History of present illness
Patient was apparently asymptomatic 10years back then he had fever difficulty in having food he was taken to hospital and found to have diabetes mellitus and was given medication. 
Patient was asymptomatic 3 yrs back and then developed pedal edema ,  facial pufiness and taken to local hospital and was diagnosed with renal failure used  medication but was not controlled . 
15 days back he had vomiting, puffiness of face ,  pedal edema, abdomen distension, loss of appetite decreased urine output. 
No history of sob, chest pain, fever, burning micturation, pain abdomen. 
History of past illness 
Diabetes since 10yrs ( insulin injection ) 
Hypertension since 1 year  ( nicardia 10mg ) 
No history of asthma, TB, cad, epilepsy. 


Personal history 
Diet - mixed 
Appetite - lost 
Bowel - regular 
Micturation - abnormal
No known allergies 
Addiction beedi stopped 5 yrs back 

No known family history 

General examination
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, malnutrition 
Pedal edema present 
Vitals

Temperature - afebrile 
Pulse rate - 75bpm
Respiratory rate 21bpm
Bp - 110/80 mm of hg 
Systemic examination 
Cvs 
Inspection 
No deformity in precordium
No kyohosis 
No scars 
Palpation 
S1 s2 heard 
No thrills
Auscultation 
No cardiac murmurs heard 

Respiratory 

Inspection 
Chest barrel  shape 
Trachea central position 
No dilated veins, scars

Palpation 
All inspectory findings confirmed
No tenderness

Percussion 
Resonant in clavicle 

Auscultation 
Normal vesicular breath sounds

Abdomen 

Inspection
Normal shape and symmetrical
All quadrants moving equally  with respiration
Umbilicus central and inverted 
No visible scars 

Palpation
No tenderness
Liver and spleen not palpable 

Percussion 
Resonate

Auscultation
No bruits heard 

Cns 
Patient is conscious
Speech normal
No neck stiffness 
Motor and sensory system normal

investigation 
9-1-23
18-1-23

Provisional diagnosis 
Chronic kidney disease 
Diabetes 10yr 
Hypertension 1 yr 

Treatment 
Tab nodosis 500mg
Tab nicardia 10mg 
Tab shelcal 
Cap Bio D3
Tab lasix 40mg 
Fluid restriction
Salt restriction







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