57 year old male with CKD

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan

A  year old male,who was farmer by occupation, came to OPD with

CHIEF COMPLAINTS :

• Increased abdominal pain since 10 days
• SOB since 10 days
• Unable to speak since 2 days


HOPI:

• Apparently pt was asymptomatic 6 mnths back
• Then he developed puffiness of face, pedal edema, abdominal pain, back ache, fever, burning micturition for which he visited a local hospital. 
• He got diagnosed with renal calculi and also shrunken kidneys for which he took medications and got relief. 
• Since 10 days, he again developed increased abdominal pain and SOB
• Also couldn't speak from 2 days

PAST HISTORY:

• k/c/o renal atrophy/shrunken kidneys since 6mnths
• NSAID abuse since 20 yrs for stomach ache ( due to bloating and gas as said by the pt) 

PERSONAL HISTORY:

• Farmer by occupation
• Appetite lost
• non vegetarian
• Bowel habits irregular
• micturition - burning micturition
• Addictions - beedi since 40 yrs 



FAMILY HISTORY :
Nil significant

GENERAL EXAMINATION :

Pallor - present
Oedema of feet - yes
Cyanosis, clubbing, lymphadenooathy, icterus, malnutrition - no







VITALS :

Temp - febrile
PR - 118bpm
RR - 30cpm
BP - 110/80mmHg
SPO2 - 98%
GRBS - 116mg%



SYSTEMIC EXAMINATION :

CVS:

S1, S2 heard
No thrills, no murmurs


RS:

Dyspnoea present
No wheeze
Trachea central
Breath sounds vesicular
No adventitious sounds

P/A:

Distended
No tenderness, palpable mass







CNS:

Conscious
Speech - no response
No signs of meningeal irritation


PROVISIONAL DIAGNOSIS :

AKI ON CKD


INVESTIGATIONS :


29/8/2022


















TREATMENT:





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