General medicine Case 4

 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 patients 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 comment box is welcome.

A 69 years old male who is farmer by profession presented to OPD with cheif  complaints of  :

 - Shortness of breath since 6  months       -  bipedal edema from 6 months.                - Reduced urine output since 6 months.   - Fullness of stomach even for small            amounts of food since 4 days. 

HISTORY OF PRESENT ILLNESS -

Patient was apparently asymptotic 1 year  ago.        

                                                                            - 1 year back patient developed mild pedal edema which was gradual onset and was progressing in nature  

 Patient also had shortness of breath but neglected the symptoms.        

    - 6 months back when the symptoms got aggravated  along with decreased urine output patient presented to nearby hospital.                                                            - There it was diagnosed as renal failure (right kidney) and was on medication and treatment(dialysis) for 4 months.

PAST HISTORY :-

-Patient was known case of diabetes mellitus and hypertension since 22 years. (got to know when he felt giddiness and went for checkup).               - Patient underwent hydrocele surgery 4 years back (which was been absconded for 10 years before he underwent the surgery).                                                           - No history of epilepsy, asthma, TB.

PERSONAL HISTORY :-

Appetite - fullness of stomach with small amount of food.                                               Diet - normal.                                                  Bowel and bladder - normal.                        Habits - occasionally consumes alcohol.                 - no smoking.                                       Martial status - married (3 children).

FAMILY HISTORY :-

Patient's brother has expired due to similar illness(untreated renal failure).   

ALLERGY  HISTORY :-

Patient does not complain of any drug or food allergies. 

Patient does not have any pollen allergy. 

GENRAL EXAMINATION :-

The patient is concious, coherent and cooperative.

On examination, patient's mood appears to be well and is well built.

 There is no lymphadenopathy present.

 There is no presence of clubbing.

 There is  pallor. 

 There is no icterus.

 There is no cyanosis.

 There is oedema of feet.

 Patient is not dehydrated

VITALS-

Temp-98* f

Pulse rate - 82 beats/ min(90 b/m before dialysis) 

Respiration - 16 cycles /min 

BP-120/80 mm/hg (130/70 - before dialysis) 

Serum creatinine - 

 Blood sugar random 

Heamogram 

Erythrocyte sedementation rate 

Blood urea

Serum electrolytes

Heamoglobin 

Provisional diagnosis :-

Chronic kidney disease 2° to diabetic nephropathy.