62 year old male patient with Chronic Kidney Disease .
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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.
A 62 year old male Mason by occupation came to OPD for dailysis.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 years ago.Then he had recurrent episodes of edema in foot in the past 3 years which subsided on taking medication from the local doctor .
But ,1month ago he started having fever, shortness of breath, decreased urine output , burning micturition for 5days.Then he went to a hospital in choutuppal where he underwent few lab investigations and was referred to Gandhi hospital. So ,Later at Gandhi he was diagnosed with renal failure after few other lab investigations and treated for dailysis for about 10 times in the past 1month.
PAST HISTORY
K/c/o Diabetes (1month)
Not a k/c/o Hypertension,Tuberculosis, Epilepsy, Asthma
PERSONAL HISTORY
Mixed diet
Normal Appetite
Adequate sleep
Regular bowel and bladder movements.
No allergies
Occasional alcoholic
No smoking
FAMILY HISTORY
Not relevant
TREATMENT HISTORY
He underwent dialysis for 10 times in past 1 month.
GENERAL EXAMINATION
Patient is coherent,conscious and cooperative .
Patient is well nourished.
Pallor present
No icterus, clubbing, cyanosis,lymphadenopathy,
Pedal edema present
Vitals
Temperature :99°F
Blood pressure:120/70 mm Hg
Pulse rate : 74 bpm
Respiratory Rate:24cpm
SYSTEMIC EXAMINATION:
Cardiovascular System: S1 and S2 heard.
No murmurs heard.
Respiratory system: vesicular breath sounds heard.
Position of Trachea: Central
Per abdomen:
Shape of abdomen: scaphoid
No tenderness
No organomegaly.
Bowel sounds heard
Central nervous system:
Conscious
Normal speech.
No neurological deficit found.
PROVISIONAL DIAGNOSIS
Chronic Kidney Disease
INVESTIGATIONS
TREATMENT
1)T.Lasix 10mg BD
2) T.Nodosis 500 mg TID
3) T.Pan 40 mg OD
4)T.Orofer XT OD
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