A 27 yr old male a known case of CKD

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 


 I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings,investigations,and come up with a diagnosis and treatment plan. 



Case senario:-
A 27 year old male patient who is known case of CKD on MHD came with chief complaints of pedal edema.

Chief complaints:-
The patient came to casuality with the complaints of shortness of breath and pedal edema since 3 days.

HISTORY OF PRESENT ILLNESS:-
patient was apparently asymptotic one month back then developed pedal edema which was gradually progressive associated with shortness of breath. 
No history of burning micturation.
No history of decreased urine output.
No history of orthopnea PND.
No history of fever.

HISTORY OF PAST ILLNESS:-
Known case of hypertension since 2 years 

PERSONAL HISTORY:-
DIET: mixed
APETITE: decreased 
BOWELS:regular 
MICTURATION:normal
HAS NO KNOWN ALLERGIES 
NO CONSUMPTION OF ALCOHOL
NON SMOKER

FAMILY HISTORY:-
No history of same complaints in family.no abnormalities detected. 

GENERAL EXAMINATION:-
patient c/c/c well oriented to time,place,person.
Moderately built,moderate nourishment. 

VITALS:-
Pulse rate: 92 bts/min.
BP:  140/90 mm of Hg       
Respiratory rate: 24/ min
Temperature:98.6 F.

PHYSICAL EXAMINATION:-
pallor:absent 
Icterus:absent 
Cyanosis:absent 
Clubbing of fingers/toes:absent 
Generalized lymphadenopathy:absent 
Edema of feet:present, pitting type.

           SYSTEMIC EXAMINATION 

CARDIOVASCULAR SYSTEM:
S1 S2 heard
No cardiac murmors

RESPIRATORY SYSTEM
vesicular breath sounds heard.
Trachea centrally in position 
No Wheezing 
Dyspnea:present
On abdominal examination:

Inspection:

Shape of abdomen is scaphoid 

Flanks are free

Umblicus is in position, inverted

Skin over abdomen normal shiny, no scars, no sinuses, no nodules, no puncture marks.

No visible veins.

No engorged veins.

Movements of abdominal wall are normal, no visible gaatric peristalsis 

Palpation: 

Liver examination:

On superficial palpation

no tenderness , raised temperature

On deep palpation

 No tenderness in liver

Non pulsatile



Spleen examination: 

No tenderness and pain



Percussion :

No fluid thrill.

No shifting dullness.


Percussion of Liver for Liver Span : 13cm



Auscultation 
No bowel sounds heard.
2. Bruit - no renal artery bruit heard.
                no iliac artery bruit heard.


ABDOMEN 
Scaphoid shaped abdomen. 
No tenderness 


CNS
conscious and normal speech
Normal gait
Cranial nerves normal 
Motor system normal


INVESTIGATIONS 



CLINICAL IMAGES 

PROVISIONAL DIAGNOSIS 
 CKD ON MHD

TREATMENT 
Tab NICARDIA 20mg PO/TID
Tab OROFER XT PO/BD
Tab ARKAMINE 0.1mg PO/TID
Tab MET XL 50mg PO/OD
Tab LASIX 40mg PO/BD
Tab SHELCAL 500mg PO/OD
Tab PRAZOSIN 5mg PO/RD
Tab TELMA 40 mg PO/ND.

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