A case of ckd




THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .




 A 49 yr old male resident of cherlapally came to the opd with the chief complaints of pain in the right lower leg since 20 days and fever since a week . 

HISTORY OF PRESENT ILLNESS 

Patient was apparently asymptomatic 2 yrs back 

Then one day he went for general checkup where some blood tests were done , in which they found his creatitine level is increased and is on medication since then . 

20 days back he developed swelling in both lower legs which are pitting , insidious in onset and gradually progressive and developed till knee 

He also has SOB since 20 days and pain in only right leg


 PAST ILLNESS 

K/C/O DM and HTN since 12 yrs and on medication 

N/K/C/O asthma , TB , epilepsy, 


PERSONAL HISTORY:

He is married. 

 Mixed diet. 

Appetite :Normal

Micturtion: normal

Bowel and bladder habits : normal

No alcohol and smoking history

FAMILY HISTORY:

Has no family h/o  HTN, TB, heart disease,cancers, epilepsy. 

Family h/o of DM (father) 

GENERAL EXAMINATION : 

Vitals :

• BP - 110/70 mmHg

• Temp. - 98°F

• SpO2 - 98%

• RR - 14 cycles/min

• PR - 86 bpm

•GRBS : 107 mg%

PALLOR : present

ICTERUS : absent

CYANOSIS :Absent

CLUBBING :Absent
 
GENERALIZED LYMPADENOPATHY :Absent

ODEMA: present in legs (bilateral) 

  
SYSTEMIC EXAMINATION :

CVS:

• S1, S2 heard

• No thrills and cardiac murmurs

RESPIRATORY SYSTEM:

• No dyspnoea, wheezing

• Postion of trachea - central

• Breath sounds - Vesicular

ABDOMEN:

• Shape  : scaphoid

• No tenderness, palpable mass, bruits

• No palpable liver and spleen

CNS:

• Conscious and coherent

• Speech - normal 

No signs of meningeal irritation

• Glass gow coma scale - 15/15

PROVISIONAL DIAGNOSIS 
CKD 


CLINICAL IMAGES 
15 days back 
The ulcer 
     


          


    

    

INVESTIGATIONS 



     





    






 TREATMENT 

28/7/2022

    

29/7/2022




30/7/2022 

     







 



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