58 year old male with CKD

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 clinical problems with collective current best evidence based inputs.

CHIEF COMPLAINTS

A 58 yr old male patient farmer by occupation came to opd with chief complaints of sob and pedal edema since 1week

HOPI

Patient was apparently asymptomatic 1month back then he developed 

Decreased urine output since 1month

sob which is of grade 4 and he also had pedal edema along with facial puffiness Since 1week 

He is also having chest pain which is radiating to back since 1week

No history of fever,cold and cough

PAST HISTORY 

Known case of hypertension since 3yrs

He is also on MHD since 3yrs

No history of DM, TB,Epilepsy, asthma, Thyroid abnormalities and CAD

PERSONAL HISTORY 

Appetite:normal

Mixed diet

Sleep:disturbed 

Bowel movements regular

Bladder movements decreased

He is toddy drinker but stopped recently


ON EXAMINATION 

Pt is conscious, coherent, cooperative

Pallor-present

Icterus-absent 

Cyanosis-absent

Clubbing-absent

Lymphadenopathy-absent

edema-present

VITALS

TEMP:afebrile(98.6f)

PR:82bpm

RR:22cpm

BP:140/90mmhg

Spo2:98% at 12Lit of o2

SYSTEMIC EXAMINATION 

CVS:S1 S2 HEARD

CNS:NAD

RESP:BAE+ B/L Basal crepts heard

P/A: obese and no palpable masses

INVESTIGATION 

ABG

PH:7.32*(7.35-7.45)

Pco2:43.5

Po2:191*(80-100mmhg)

Hco3:22.2

HEMOGRAM

Hb:9.1*(13-17g/dl)

Total count:5900

Neutrophils:65%

Lymphocytes:25%

Eosinophil:4%

Monocytes:6%

Basophils:0

PCV:27.75*(40-50vol%)

MCV:96.3fl

MCH:31.8pg

MCHC:33%

RDW-CV:14.7%*(11.6-14%)

RDW-SD:51.2*(39-46)

RBC:2.88millions/cc*(4.5-5.5)

RFT

UREA:97mg/dl*(12-42mg/dl)

CREATININE:5.6mg/dl*(0.9-1.3mg/dl)

Uric acid:4.6mg/dl

Calcium:9.2mg/dl

Phosphorus:2.5mg/dl

Sodium:138meq/l

Potassium:4 meq/l

Chloride:98meq/l

ECG:


CHEST RADIOGRAM


PROVISIONAL DIAGNOSIS

CKD ON MHD

TREATMENT:

Fluid restriction (<1.5l/day)

Salt restriction (<2g/day)

Tab.LASIX 40mg BD

Tab.METOR 5mg OD

Tab.OROFER X5 OD

Tab.NODOSIS 500mg BD

Tab.SHELCAL 500mg OD

Tab.BIO D3 0.25mg OD 

Tab.NICARDIA 300mg OD 

Tab.ARKAMINE 0.1mg TID

Tab.PAN 40mg OD









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