19 Lavanya blog spot.case study

B.Lavanya 
Roll no 19 

This is an online e - log platform to discuss case scenario of patient with their guardian's permission 

*CASE SCENARIO : 
A 75 yr old male patient resident of Suryapet came to causality with cheif complaints of breathlessness 

Complaints and duration : 
CKD 
Pedal edema 
Facial puffiness since 3 days 
Shortness of breath 

History of present illness : 
No h/o present illness 

History of past illness : 
CkD on MHD ( analogue to nephropathy ) 

Treatment history : 
No h/o Diabetes 
No h/o CAD 
No h/o asthma 
No h/o tuberculosis 
Hypertension is present ; 
H/o blood transfusion (1) and surgery (1)

Personal history : 
Loss of appetite 
Bowel movements are regular 
Micturition is abnormal 
No unknown allergies are seen 

Family history : 
No H/ o of diabetes , hypertension , stroke,  cancer , Tb, asthma .

General examination : 
Patient is pallor no icterus 
No cyanosis 
No clubbing of fingers
No Lymphadenopathy .
Edema of feet is seen 
No h/o  malnutrition 
No h/o dehydration 

Vitals : 
Temperature : 98.4 F 
Pulse rate : 86 beats / min 
Respiratory rate : 18 / min 
Bp : 110 / 70 

Systemic examination : 
CVS 
No thrills 
No cardiac murmurs 

Respiratory system : 
Dyspnoea is seen 
No wheezing sounds 
Position of trachea is central 
Breath sound - vesicular 

 Abdominal examination : 
Shape - scaphoid 
No tenderness 
No palpable mass 
Liver and spleen - non palpable 
Bowel sounds are present 

CNS : 
Patient is conscious 
Speech normal 
No neck stiffness 
Cranial nerves , motor and sensory system are normal 

Provisional diagnosis :CKD ON MHD 

INVESTIGATIONS :: 

Treatment : 

3 - October 2021 
Fluid restrictions <1 litre / day 
Salt restriction < 2 grm / day 
TAB .NiCARDIA 10 mg BD 
TAB .NODISIS 500 mg OD 
TAB .SHELCAL 500 mg OD 
TAB .LASIX 40 mg 
TAB. OROFER -XT  BD 
BP ,PR , TEMP , SPo2 monitering 
4 - October 2021 
Fluid restriction - <1 litre / day 
Salt restriction - <2 grm / day 
TAB . NICARDIA 10 mg BD 
TAB .NODOSIS 500 mg OD 
TAB .SHELCAL 500 mg <OD 
TAB. LASIX 40 mg 
TAB.OROFER-XT  BD 
BP , PR , TEMP ,SPo2 monitering 

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