A 45 year old male with bilateral pedal oedma, shortness of breath and decreased urinary output.


This is 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 comments on comment box is welcome.

Vignatha 9th semester

roll no: 45

I've 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.

Following is the view of my case:

A 45 year old male came to the hospital with the chief complaints of bilateral pedal oedema, shortness of breath and decresed urinary output.


History of present illness:

Patient was apparently asymptomatic 3 months back then he developed bilateral pedal edema which was painles and it is of pitting type. He also complained of shortness of breath, lower back pain and decreased urinary output. There is no history of fever, nausea and vomitings.

Past illness: He was diagnosed with hypertension 3 months back. There is no history of diabetes, TB, asthma.

Personal history:

Appetite: normal

Diet: mixed

Bowels: normal

Micturition: abmormal

No addictions 

Family history: not significant 

General examination

Built: moderate 

No pallor, icterus, cyanosis,  clubbing and lymphadenopathy .

Vitals: 

Pulse: 89/min

Respiratory rate:26/min

Temperature: afebrile

Systemic examination

Cvs: s1 and s2 heard

Respiratory system: no dyspnoea and no wheeze.

Abdomen: distended 

CNS: Conscious, and speech is normal

Hemogram:

Renal function test

Ascitic fluid amylase

Hemoglobin in ascitic fluid 

PCV - Ascitic fluid


SAAG

Ascitic fluid protein sugar

Ultrasound report



Provisional diagnosis 
CKD on MHD
Treatment:
T. Lasix 40mg
T. Nicardia 20mg
T. Orofer
T. Nodosis 500mg
T. Shelcal 500mg
Inj. Erythropoietin 4000IU
Inj. Iron sucrose 1 amp in 100ml NS






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