70 yr old male labourer with came to opd with sob and bilateral pedal oedema

70yr old patient with ckd

January 01,2023

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 

 -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-cen

tred online learning portfolio and your valuable comments on comment box is welcome. 

Nitin Raj

03

CHIEF COMPLAINTS: c/o bilateral pedal oedema since 10 days,decreased urine output since 3 days,sob.

HISTORY OF PRESENTING ILLNESS:patient was apparently asymptomatic 10 days back rhen he developed bilateral pedal oedema(pitting type) from 10 days up to knee joint,decreased urine output from 3 days with sob grade 2, initially it was grade 1 progressed to grade 2 .history of loss of appetite and nausea

. No history of fever

. No history of burning micturition

. No history of loose motions

HISTORY OF PAST ILLNESS:

  N/k/c/o:HTN,DM,ASTHAMA,CAD,EPILEPSY,HYPOTHYROID,

TREATMENT HISTORY:History of nsaid abuse

PERSONAL HISTORY:

. Diet mixed

. Appetite normal
. Micturition normal

. Bowel and bladder movements regular

ON EXAMINATION

Patient is conscious ,coherent and cooperative

well oriented to time,place and person 

pallor

No icterus 

No cyanosis 

No lympahdenopathy

Pitting type of oedema(bilateral)

On the time of admission:

 Temperature- 98.6 c/f

Pulse rate- 82 b/m

Respiratory rate- 16 cpm

Bp- 130/80 mmhg

GRBS- 125mg/dl

ON SYSTEMIC EXAMINATION

CVS-S1,S2 heard

No murmurs

RS- BAE +

ABDOMEN- inspection- scaphoid shape

                                             No tenderness,skin is smooth and shiny,no scars,sinuses

 

Palpation- no local rise of Temperature,tenderness absent,guarding present,hernial orifice normal,fluid thrill absent,liver not palatable,seen not palpable

CNS- conscious,speech normal,no signs of meningeal irritation,sensory and motor system normal,gait- normal.

DIAGNOSIS- CHRONIC KIDNEY DISEASE SECONDARY TO NSAIDS

Investigations 

 

TREATMENT:-

. Injection lasix 40 mg iv BD

. TAB nodosis 50 mg po BD

. TAB shelcal 50 mg po BD

. TAB Nicardia 10 mg po BD

. Cap biod3 weekly once

. TAB DYTOR 20mg po.BD

. Vitals monitoring 6th hourly.