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 

     







 



Comments

Post a Comment

Popular posts from this blog

70M ALTERED SENSORIUM ET TUBE INSITU

Image
  70 year male was bought to Casuality in an intubated state HOPI: Pt is apparently asymptomatic until  2 days ago then he developed sudden onset of abdominal discomfort  and SOB after dinner. Patient was taken to nearby hospital in altered sensorium and was found Grbs-30 mg/dl . patient was intubated i/v/o poor GCS-5/15 and was bought to our hospital for further management with ET tube in situ PAST HISTORY: H/O Right inguinal surgery on 15/09/23 K/c/o hypertension since 12 yrs( on unknown medication) K/c/o Pulmonary Tuberculosis 30 years back( used ATT for 6 months) PERSONAL HISTORY: DIET :mixed APPETITE : Normal SLEEP: adequate  BOWEL AND BLADDER :Regular  Addictions : Patient was an Alcoholic and smoker 30 years ; stopped after diagnosed with Tuberculosis. FAMILY HISTORY:  N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders. GENERAL EXAMINATION: Patient is on Mechanical ventilation. Dilated neck veins present. No Pallor,Icterus,clubbing,cynosis. VITALS: TEMP: 97.2 F BP: 160
Read more

29Y/M with CKD

Image
  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 INPUT.     This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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 diagnosis and treatment plan Chief complaints : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right s
Read more

A 75 yr old female

Image
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 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 inputs on the comment box is welcome.” A 75 yr old female resident of Miryalaguda came to the opd witb the chief complaint of decreased urination and pedal edema  since 4 days  HISTORY OF PRESENT ILLNESS Pt was apparently symptomatic 4 days back then she developed severe itching due to mosquito bite following which she scratched that resulted in bleeding and she used hot water to wash the area then she had a feeling of something crawling on the leg . She has pedal edema since then  She has decreased urine o
Read more