55 year old k/c/o chronic kidney disease with pedal edema since 10 days
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 comment box is welcome."
CHEIF COMPLAINTS
The patient is a 55-year-old resident of Kodada who works as a labourer
Came for regular dialysis session
HISTORY OF PRESENTING ILLNESS
He presented with multiple complaints, including a history of alcohol use for 10 years until 2006 when he was between 25 to 40 years old. Stopped alcohol consumption upon taking up the ayyappaswamy ritual completed the pilgrimage to Ayyappa Swamy approximately 50 times, between the ages of 25 to 30 when he worked as a toddy tapper. During these days he experienced severe lower limb pains upto the level of ankles which were insidious in onset and gradually porigeessive in nature associated with pedal edema ,pedal edema that worsens upon walking but is relieved by taking NSAIDs.,for which patient used to take NSAIDS prescribed by rmp in a regular basis (weekly twice on average ),he also received injection at the RMP clinic for the same on several occasions ,
His kidney failure was incidentally found and He has been experiencing high blood sugar for the last 4 years which was incidentally found out through investigations done in order to treat his lower limb pains
shortness of breath for the past days , which improved with RMP medication. He also reported feeling giddy on regular basis (one episode today in the morning ) and having decreased urine output associated with urinary hesitancy for a year
PERSONAL HISTORY
The patient has two sons, elder son is married ,one married daughter who is pursuing PhD in pharmacy in hyd , and younger son who is 30 years .
SURGICAL HISTORY
He has a surgical history of hydrocele which he developed on lifting heavy jute sacks along with hydrocele he had also developed umbilical hernia (not treated ,asymptomatic ever since )and cataract surgery in 2015.
Additionally, he has undergone 10 dialysis sessions in August.
PAST HISTORY
K/c/o type 2 DM since 4 years
History of hydrocele and umbilical hernia 10 years back
FAMILY HISTORY
No similar complaints in family
Family was a diabetic
75 years
Wife -diabetic
Mother is hypertensive
6 brothers -4 of them are diabetic
TREATMENT HISTORY
calcitriol tablets
Oha’s since 4 years
GENERAL EXAMINATION
PALLOR -present in lower palpebral conjunctiva
ICTERUS -absent
CYANOSIS -absent
CLUBBING -absent
LYMPHADENOPATHY -absent
PEDAL EDEMA -present upto ankles ,pitting type
VITALS
- Blood pressure: 140/90 mmHg .
- Heart rate: 60-100 beats per minute.
- Respiratory rate: Around 20-30 breaths per minute.
- Temperature: Roughly 36.5-37.5 degrees Celsius
HEAD TO TOE EXAMINATION
PER ABDOMEN EXAMINATION
CVS EXAMINATION
INSPECTION
Inspection:
Chest is elliptical & bilaterally symmetrical
Trachea appears to be central
Movements appear to be equal on both sides
Percussion:
Resonant note heard in all areas
Auscultation:
Bilateral air entry present
Normal vesicular breath sounds were heard
Fine crepts heard bilaterally in mammary, infra mammary, axillary, infra axillary & infra scapular areas
PER ABDOMEN:
Obese abdomen
Midline everted umbilicus with umbilical hernia
No visible pulsations/engorged veins/sinuses
Soft, non-tender, no organomegaly, no free fluid
Bowel sounds present
CENTRAL NERVOUS SYSTEM:
HMF - Intact R. L.
MOTOR SYSTEM: Power: UL 4/5 4/5
LL 4/5 4/5
TONE - Normal.
REFLEXES - B. T. S. K. A. P.
R. +2 +2. +1. +2. --. Flexion.
L. +2. +2. +2. +2. --. Flexion.
CRANIAL NERVES - Normal.
INVESTIGATIONS
PROVISIONAL DIAGNOSIS
Chronic kidney disease probably secondary to diabetes
TREATMENT
Maintance hemodialysis
Comments
Post a Comment