CKD SECONDARY TO DIABETIC NEPHROPATHY

A 48 YRS OLD MALE PATIENT WAS PRESENTED TO THE OPD WITH COMPLAINTS OF OEDEMA AND SHORTNESS OF BREATH

CHIEF COMPLAINTS:

cough since 6 months
shortness of breath since 2 days
oedema since 2 days

HISTORY OF PRESENT ILLNESS:

the patient was apparently asymptomatic two and half months ago when he developed fever, burning micturition, pedal oedema which progressed to anasarca, he was diagnosed with AKI and is on maintainance hemodialysis.

2 days ago he had excurbation of shortness of breath especially during night time, oedema and cough because of which he came to the hospital.

HISTORY OF PAST ILLNESS:

h/o diabetes since 4 years

h/o hypertension since 2 years

h/o hypothyroidism since 6 months for which he takes thyronorm 50 mg

FAMILY HISTORY:

no significant family history

PERSONAL HISTORY:

married

h/o consumption of alcohol occasionally

no h/o smoking

diet mixed

normal bowel and bladder movements

GENERAL EXAMINATION:

Patient is conscious, coherent and co-operative

no audible wheeze/stridor

no hoarseness of voice

pallor present

no clubbingg

no cyanosis

bilateral pitting type oedema

CVS:

s1 s2 heard

no murmers

RESPIRATORY:

no dyspnoea

no wheeze

position of tracea- central

ABDOMEN:

liver not palpable

spleen- not palpable

no bowel sounds

CNS:

the patient was conscious coherrent

normal speech

sensory and motor system intact

PROVISIONAL DIANOSIS:

CKD secondary to diabetic nepropaty

INVESTIATIONS:

TREATMENT:

maintainance haemodialysis

fluid restriction
salt restriction
tab lasix
tab nicardia
tab met-xl
tab tyronorm
tab uroen
inj actrapid
neb budecort-6th hrly ; dubolin - 8th hrly
tab azitromycin
tab montek
syp benadryl

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1st internal assessment answersheet

60 year old female with convulsions

The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-log also reflects my patient's centered online learning portfolio. 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 providing treatment best to our skills and wisdom. A 60 year old female, resident of Nalgonda district, farmer by occupation, presented with CHIEF COMPLAINTS: Involuntary movements and loss of consciousness HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 20 years ago, when she...

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