A 65 year old female 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. 

Chief Complaint: 
A 60 years old female with chief complaints of
- Decreased urine output since - 3 months
-pedal edema since - 3months.
Shortness of breath since - 3 months

History of present illness:- 
patient was apparently asymptomatic 1yr back then she noticed decreased urine output and was diagnosed with heart failure and renal failure and started on conservative management. 
Then 3months back she noticed increased Bilateral pedal edema -pitting type, extending till ankles . 
shortness of breath - grade 3(MMRC) insidious onset and progressive. 
Orthopnea is present .
No history of burning micturition, cough, cold, fever.

History of past illness: - 
K/C/O Hypertension since 30 years, diabetes mellitus since 30 years
Not known case of asthma, tuberculosis, epilepsy.

Systemic Examination -   
  
Respiratory system 
Inspection : -
Chest is normal bilaterally symmetrical 
Position of trachea is central 
Movements are bilaterally symmetrical.
No scars , sinuses, or visible pulsations.
Suprasternal and supraclavicular notching is present.
Palpation :
No local rise of temperature
No tenderness
All inspectory findings are confirmed
Apex beat felt in 5th intercostal space lateral to midclavicular line .
Percussion
Resonent sound is heard
Auscultation 
Normal vesicular sounds are heard.

CVS -
inspection :
Bilaterally symmetrical chest
No visible engorged veins,scars or sinuses on chest.
Palpation :
S1 S2 are heard
Apex beat present at 5th intercostal space lateral to midclavicular line .
Auscultation : 
Cardiac rate - 100 beats per minute 
No cardiac murmurs heard.

Abdomen - 
Obese, inverted umbilicus. 
No visible scars, sinuses, fistulas, engorged veins.
No organomegaly. 
Soft , non tender , no free fluid. 
CNS -
Conscious, speech is normal, no neck stiffness
No finger and nose in coordination.

Provisional Diagnosis: - Chronic renal failure 

Investigations: - 
2D echo 
USG ABDOMEN
complete urine examination
Random blood sugar
Serum creatinine
Serum electrolytes
ECG 
Complete blood picture 


  

 Management:- Hemodialysis
Tab Nodosis
Tab shelcal
Tab orofer
Cap BioN
Tab Nicardia
Inj Erythropoietin
Salbutamol nebulisations

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