A 62 year old male Patient with CKD on MHD


This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 
CHEIF COMPLAINTS :-
A 62 year old male patient farmer by occupation, resident of Nalgonda came to OPD with cheif complaints of Pedal edema since 2 years and Shortness of breath since 2 months.

HISTORY OF PRESENT ILLNESS:-
Patient was apparently asymptomatic 5 years back then he developed SOB(Grade 3) which is sudden in onset and gradually progressive and relieved on lying down, diurnal variation present more in night and not associated with fever, cold, cough, chest pain and developed pitting type of pedal edema since 2 years.

HISTORY OF PAST ILLNESS:-
Known case of Hypertension since 2 years and under medication-Stamlo 5mg/PO/OD
Not a known case of Diabetes mellitus,  Asthma, CAD, Tb, Epilepsy.
NSAIDS abuse

PERSONAL HISTORY:-
Married
Diet-Mixed
Appetite-Normal 
Bladder and Bowel movements-Regular 
Micturition-Normal 
Occasionally alcoholic 
DRUG AND ALLERGY HISTORY:-
No known relevant drug and allergic history

FAMILY HISTORY :-
No significant family history. 

GENERAL EXAMINATION:-
Patient is concious, coherent, cooperative and well oriented to time, place and person.
No Pallor
No Icterus
No Clubbing
No Cyanosis
No Lmphadenopathy
No malnutrition. 
Pedal edema present

VITALS:-
Temp-98.4 F
Pulse rate-88/min
Respiratory rate-30cpm
BP-130/80 mm Hg
Spo2-98%

SYSTEMIC EXAMINATION:-
Respiratory system-
Dyspnea present 
No wheeze
Trachea-Central
Decreased breath sounds
Abdomen- shape is distended
                 - No Tenderness 
                 - Liver,spleen not palpable
                 - Bowel sounds heard
CVS-S1 S2 Positive
CNS- Pt is concious 
        - no signs of meningeal irritation
        -cranial nerves, motor system, sensory system are normal

PROVISIONAL DIAGNOSIS:-
CKD on MHD


INVESTIGATIONS:-
CBP
Random Blood Sugar
ECG
RFT
Colour Doppler 2-D Echo


TREATMENT:-
Tab. Nodosis 500mg PO/BD
Tab.Lasix 20mg PO/BD
Tab.Nicardia 20mg PO/TID
Inj.HAI SC/TID
Cap.Bio D3 PO/weekly once
Tab.shelcal 500mg PO OD
Tab.orofer XT PO/OD
Tab.Revalmer 400mg PO/TID
Tab.Ecosprin
Neb.Budecort


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